Introduction :Tumoral calcinosis has long been a disputed clinical-pathological subject. It has been characterized by the deposition of calcium salt and hydroxyapatite in different periarticular soft tissue regions. Most commonly seen in adults, and rarely seen in children. Case Presentation : we present the case of a 6-year-old girl referred to our institution for one year with a history of left hip pain and swelling. The patient underwent an open reduction of left hip and acetabuloplasty for developmental hip dysplasia (DDH) at the age of two years. Systematic investigations were performed and showed that the patient had abnormal calcifications and large, ill-defined lesions with an irregular margin on the left hip extended to the left gluteal area with skin ulceration suggestive of primary tumor calcinosis. Medical therapy has started, and a follow-up appointment was given to her in a pediatric metabolic clinic. Conclusion : The clinical course of tumoral calcinosis and pathogenesis remains understood. The diagnosis of tumoral calcinosis is based on clinical evaluation, imaging modalities, and histopathologic examination. Treatment of tumoral calcinosis should be correlated with the patient and the clinical situation. Treatment options included both medical therapy and surgical intervention. It is better to start medical therapy in the early stage of the disease prior to surgical intervention. However, we need to conduct multiple large studies to show the effect of medical therapy in a patient with tumoral calcinosis.

Brodie's abscess consists of an uncommon subtype of osteomyelitis presenting with intraosseous abscess. Infantile form is predominantly due to Kingella Kingae and juvenile form due to Staphylococcus Aureus. Its diagnosis is challenging due to nonspecific symptoms and slight increase in inflammatory markers. The authors report a case of a 16-month-old toddler with a one week history of claudication. Recently a viral gastroenteritis had been diagnosed. On physical exam, restricted motion of the left hip and pain with weight bearing were noted. White-blood-cell count and C-reactive-protein were normal but erythrocyte-sedimentation-rate was increased. Initial diagnosis of transient hip synovitis was made. One week later, the patient returned. On plain radiographs of the left femoral neck, an area of central lucency surrounded by sclerotic margins was identified. Magnetic resonance findings were suggestive of Brodie’s abscess (“penumbra sign”) but an osteoid osteoma could not be excluded. Oropharyngeal swab polymerase-chain-reaction was positive for Kingella kingae. The patient was submitted to surgical drainage through drilling of the femoral neck. Empiric antibiotherapy with cefuroxime was started. Kingella kingae was also identified in the femoral neck drainage with sensitivity to cefuroxime. Following 12 days, oral cefuroxime was started. A total of 12 weeks of antibiotherapy was completed. Currently, at 8 months follow-up radiographs show resolution of the lesion. Our case was more challenging due to history of recent viral infection and location of the lesion since the femoral neck and surrounding metaphyseal region is a less commonly affected site. Surgical drainage and antibiotherapy yielded a good outcome.

We present the case of a 13-year-old boy who sustained an avulsion of the anterior inferior iliac spine during soccer practice. The fracture was initially overlooked, but after two-weeks the patient returned to the emergency service and the injury was diagnosed. Because he was a competitive soccer player with high function demand and the bone fragment was displaced by 20mm, surgical treatment was proposed. Fragment fixation was done through a minimally invasive anterior approach with a partially threaded screw. Post-operative evolution was eventless and the patient returned to sports after 3 months of physical therapy. At the end of follow-up, he did not present pain or limited range of motion.
Anterior inferior iliac spine fractures occur after forced contraction of the rectus femoris, most commonly in male adolescents, and are sometimes mistaken for soft-tissue injuries. Conservative treatment is done in most cases with good results; however, weight bearing restriction can be needed for up to 6 weeks and complications such as chronical pain, non-union and subspine femoroacetabular impingment are described. Surgery should be considered in displaced fragments and higher demand patients, such as athletes. Doubt remains as to whether primary surgical treatment is advantageous in comparison to secondary treatment of complications.

Introduction: Aneurysmal bone cysts are benign lytic lesions that appear more frequently at a young age and have a high potential for recurrence. These lesions typically appear on the spine and metaphysis of long bones. Aneurysmal cysts of the astragalus are extremely rare lesions.
Case description: The authors report the case of a 15-year-old girl who presented to the outpatient clinic with sporadic pain with load on her right ankle. After imaging with radiography and magnetic resonance, it was concluded to be an aneurysmatic cyst of the astragalus. Curettage of the lesion and filling with autologous bone graft of cancellous bone of the iliac crest were performed. The patient had an excellent functional result with full weight bearing at 3 months. Follow-up will be maintained due to the possibility of recurrence of the lesion.
Discussion: Curettage and filling with bone graft is the standard treatment for long bone injuries, and adjuvant treatments can be performed. There are several reports of good results with this type of surgical treatment applied to lesions located in the astragalus. Due to the high frequency of local recurrence of aneurysmal cysts, it is extremely important to maintain frequent reassessments due to the risk of joint damage or acute fracture.
Conclusion: Although rare, the presence of aneurysmal bone cysts should be considered when detecting an osteolytic lesion of the astragalus.

Case presentation: A sex-year-old child presented to the emergency room with a wound on the left Achilles tendon after suffering a direct sharp trauma to the location of this tendon 1 hour earlier. Physical examination showed a nonreactive Thompson test and a reduced plantarflexion strength compared to the contralateral side. The neurovascular examination was normal. The wound was cleaned and inspected and a total laceration of the Achilles tendon was found. There were no associated vascular or nerve injuries. Under local anesthesia and sedation, a primary repair of the tendon was performed, using a Kessler suture, and a cast was applied with the foot in plantar flexion. Three weeks later, the cast was changed positioning the ankle in a neutral position. This cast was removed one week later, and physiotherapy was initiated. During follow-up, there was a very good clinical evolution, with progressive increase in mobility and strength of the lower limb. There was a thickening of the distal insertion on the Achilles tendon, without clinical repercussion or pain on palpation. Discussion: Achilles tendon laceration is a much less reported injury, when compared to Achilles tendon rupture. Contrarily to the rupture, in a laceration there is a complete disruption of the continuity of the fibers, and consequently a retraction of the proximal stump of the tendon. Studies have shown that treatment of laceration should be evaluated differently and surgical treatment should be performed even in pediatric patients with complete laceration.

Osteochondromas are benign osseous tumours often diagnosed sporadically and patients are usually asymptomatic. However, in some cases, symptoms arise from compression, such as impingement of vascular or nervous structures. Prompt recognition and treatment is important to ensure good clinical outcomes. This presentation reports a clinical case of a 15-year-old patient with a sessile osteochondroma of the right proximal fibula. The patient recalled feeling a hard protuberance in the right leg for many years, and started to manifest neurological symptoms one year before clinical observation. At presentation, the child appeared with foot drop, lower limb anaesthesia and marked functional deficit. Electromyography describes very severe lesion of the deep peroneal nerve and partial lesion of the superficial peroneal nerve. The patient was promptly submitted to excision of the sessile osteochondroma, later confirmed with pathological analysis. After surgery, gradual but slow neurologic improvement was observed. At 16-months follow-up, the patient exhibited complete range of motion of the lower limb, full motor function and no sensorial deficits, and was discharged.

Neurovascular injuries asociated with closed fractures are unusual complications. It is important to make an early diagnosis and treatment in order to avoid serious consecuences for the limb.
A 15-year-old male suffered a high-energy bicycle accident.
The X-rays showed a Salter–Harris IV fracture of the proximal tibia with anterolateral epiphyseal displacement and bone comminution.
Physical examination: knee deformity without solution continuity, hypoesthesia in the dorsum of the right foot, inability to dorsiflex the ankle and absence of dorsalis pedis pulse and posterior tibial pulse after closed reduction. CT-Angiography was performed, which showed a defect in the 2nd portion of the popliteal artery.
Emergency surgery performed by vascular surgery and traumatology services: External fixation, reparation of distal popliteal artery dissection using a bovine pericardium patch, open reduction and plate fixation through a medial approach and fasciotomies of the 4 compartments.
Second look 48 hours later: fasciotomies closure.
5 weeks after the surgery, the external fixator was removed, partial weight bearing and joint mobilization were allowed.
The neurophysiological study showed external popliteal sciatic nerve damage.
9 months after the accident, the patient has no gait disturbance, complete articular balance, muscle strength 4/5 in the extensors of the right foot and a limb length discrepancy of 1,6 cm corrected by wearing a 1 cm shoe lift.
Vascular injuries not only can compromise the function of the limb but also can produce serious systemic consequences. Therefore, fractures associated with vascular injury requires urgent diagnosis and a multidisciplinary approach.

Synovial osteochondromatosis is an uncommon disorder that usually affects large joints between the 3rd and 5th decade of life, being very rare in childhood. It is a benign pathology, however, it can produce local complications and degenerative changes.
We present a case of a 7 year-old girl with swelling in her right ankle, no previous trauma. She reported pain during physical activity and hypoesthesia in the external region of the ankle, without infectious signs.
X-Ray: free osteochondral bodies in sinus tarsus, tibiotalar and subtalar joint.
MRI: several free articular bodies of different sizes and stages of calcification, joint effusion and diffuse synovial thickening. No associated osteochondral lesions or bone edema were observed.
Given the symptoms and the radiological images, ankle arthroscopy was performed.
Posterior approach: Synovectomy and extraction of numerous free osteochondral bodies were performed through arthroscopic portals.
Anterior approach: Through the anterior portals two large anterolateral osteochondral fragments were observed. An open anterolateral approach was required to remove the tumors.
The samples were sent to Pathology service where the diagnosis was confirmed.
The clinical evolution of the patient was excellent, at 3 months she had complete joint balance, no pain or palpable tumors, and normal vascular and nervous state.
Conclusion: Imaging studies, clinical examination and anamnesis are essential in the diagnosis of synovial osteochondromatosis and indicate the need of surgical treatment. Arthroscopy allows early recovery with less postoperative pain with few complications. It is always possible to turn it into an open surgery if necessary.

Introduction
Epiphyseal stapling is a method of guided bone growth using metal staples implanted across growth plate near joint to temporarily prevent it growing. It is used for correction mainly angular deformities of the children’s knee. Correction of deformity proceeds proportionally to growth activity of non-restrained part of the physis.
Materials and Methods:
The goal of the experiment was to assess the behavior of angled staples used for treatment in a model of proximal tibia growth plate. The model was used to evaluate the epiphyseal disk for simulation of bone growth. Provided models of bone were then put into environment of real treatment, to slow growing from epiphyseal disk. Final model was then imported into software for further computations.
Results:
From the analysis of stress-deformation testing we can determine that the maximal stress occurs in parts of bone staples with radius and narrowed cross sections. Maximal deformation occurs in sections of staples which are located inside proximal tibia, due to growth of bone, which pushes these parts upwards.
Conclusions:
Used staples are made from medical grade stainless steel 1.4441. Minimum yield strength of this material is 690 MPa. The calculated maximal equivalent von Mises stress in bone staple is = 642.73 MPa. This stress is less than minimum yield stress. Calculated total maximal deformation of staple is ∆l = 0.125 mm. Bone growth was performed through overloading by tensile force 980.7 N ≈100 kg. acting in epiphyseal disk. For future endeavors, to verify these results, an experiment should be done.

Introduction
Multiple pathological processes may result in an increase in pressure within a muscular compartment, giving rise to the so-called compartment syndrome, an acute condition of the limb that threatens its integrity and is typically treated with emergency fasciotomies.

Goals
To present an extremely rare case of compartment syndrome in the upper arm compartment due to CPT-2 dysfunction and to evaluate its complex diagnosis and treatment.

Material and methods
26 years-old patient with history of syncope on exertion was admitted to ICU after presenting cardio-respiratory arrest during exercise. Analytically, a progressive increase in CK was observed up to 314157U-I.This required urgent ECMO placement due to poor response to pharmacological treatment.
24 hours after admission, there was an increase in volume in both arms with edema and high pressure in the triceps compartment. Impossibility of neurological-clinical examination.
After clinical evaluation of the patient and confirmation of compartment syndrome of unknown duration, risk/benefit of fasciotomies was assessed in a patient anticoagulated by the use of ECMO; Therefore, surveillance, initial physical measures and treatment with IV corticosteroids were indicated.

Results
A genetic study diagnosed the patient with CPT-2 dysfunction, which caused rhabdomyolysis and compartment syndrome (treated conservatively given the risks).At 5 months, patient presented a bilateral deficit in wrist and finger extension.

Conclusion
Compartment syndrome associated with cardio-respiratory arrest is one of the rarest pathologies in young patients. Management of these patients should be assessed by giving priority to their general condition and always assessing the risk-benefit of the technique to be performed.

Introduction: Thoracolumbar (TL) kyphosis frequently resolves spontaneously in infants with achondroplasia, a few develop progressive kyphosis. Congenital lumbar canal stenosis (LCS) is another known association. We describe a rare presentation of severe neurological deficit due to both severe TL-kyphosis and LCS in achondroplastic child. Case report: A 15-year-old male child presented with progressive bilateral lower limb weakness over 2-months. He had mixed UMN and LMN on signs such as Babinski sign, hypotonia and absent deep tendon reflexes. He was not able to walk (Frankel-B) and had a high post-void residual urine volume suggestive of detrusor muscle weakness. Rectal tone and voluntary anal sphincteric contraction were normal. Sitting and supine radiographs revealed he had fixed TL-kyphosis of 69degree with apex was at T12. The MRI showed spinal cord tenting at T11-12 and T12-L1 discs and multilevel congenital central and lateral recess stenosis from L1-L2 to L3-4 (L4 and L5 were sacralized). The patient was operated with posterior vertebral-column-resection at T12-vertebrae level and multilevel laminectomy extending to L4-level. T10-L2 instrumented fusion was done. Patient started showing neurological improvement 3-months after surgery, however, could not pass urine voluntarily. At final follow-up of one year, the child was ambulatory (Frankel-D) with support of a walker and required intermittent self-catheterization. Conclusion: An early diagnosis and surgery of the TL-kyphosis before the onset of neurological symptoms could have prevented the neurological deficit. We would recommend that patients who are older than 5-years with progressive TL-kyphosis, especially over 50-degrees should get prophylactic surgery to prevent this complication.

INTRODUCTION: Osteoid osteomas are benign bone tumors characterized by formation of a nidus of vascular osteoid tissue surrounded by a margin of sclerotic bone . They account for 11% of all benign bone tumors, have a predilection for the appendicular skeleton , usually the lower extremity where the femur or tibia are involved in nearing half the cases. In this study we aim to assess the spectrum of presentation of osteoid osteoma in children. MATERIALS: This is a retrospective study , for which the data was collected from the patients admitted in Indira Gandhi Institute of Child Health- Bangalore during January 2011 to November 2018 . Children of the ages between 2 to 17 yrs, including both sexes , with definitive radiological or clinical evidence or a biopsy proven osteoid osteoma were included in the study . RESULTS : Total 16 cases were found. 5 patients had lesions in the femur, 4 in tibia. There were few cases with rare presentation in anterior element of spine, calcaneum and foot. All of the children had chronic unexplained pain of involved site with majority of them diagnosed late. 14 patients were treated surgically with excisional biopsy. No postoperative complications and recurrence were noted. CONCLUSION: The spectrum of presentation of osteoid osteoma in children is variable, the clinician should be aware of the presentation of the same at unusual sites . They tend to have a benign course and are usually managed by Surgical excision having good results .

Simple bone cysts are benign lytic bone lesions, usually found in children. It mainly involves long bones, especially proximal humerus and femur. Usually these lesions are discovered accidentally but sometimes they can be symptomatic. The authors present a case of a 5 year-old girl who presented with 1 week evolution right hip pain, without a traumatic origin. She had no fever or other constitutive symptoms. Clinically it was obvious a limp and pain with passive internal rotation. The X-ray showed a well-contoured, unicameral, lytic bone lesion of the right femoral neck. CT scan revealed a trochanteric and femoral neck thin-walled unicameral cystic lesion that occupies > 50% of bone diameter. It was an homogeneous lytic lesion, with sclerotic border, no periosteal reaction, cortical disruption or soft tissue abnormalities. The authors performed a percutaneous aspiration with harvest of microbiological and pathological samples, curettage and filling with, biocompatible and exothermic ideal reaction, synthetic bone cement (Kryptonite). We got an immediate postoperative and a long-stand recover with this simple and harmless technique. The histopathological analysis confirmed a simple bone cyst lesion. The patient has actually nine years of follow up and she had a complete recovery without complications. She had no limitations at her daily life activities including sports. The bone cement was partially reabsorbed and bone ingrowth along the cement can be seen. This was a less invasive treatment of a simple bone cyst, who was conditioning an eminent risk fracture and could be the origin of a worse prognosis clinic situation.

Staphylococcus aureus is the major cause of septic arthritis and osteomyelitis in children.Over the last years the prevalence of Methicillin-Resistant Staphylococcus aureus (MRSA) has increased worldwide.However there is limited data about the prevalence in Portuguese children.
Case of a 15-year-old-boy,previously healthy, who came to the emergency department complaining of fever and left knee pain.Physical examination revealed a warm and lightly swollen knee with painful and limited flexion. Portal of entry was not identified.
Laboratory findings included leucocytosis,high C-reactive protein and erythrocyte sedimentation rate.
An ultrasound and computed tomography of the knee were inconclusive.
As clinical and laboratory findings were worsening it was decided to drainage and lavage of the joint space by open arthrotomy,and initiate intravenous flucloxacillin.
Five days after admission,MRI showed osteomyelitis and abscess of the distal part of femur.
The patient was submitted to abscess drainage,debridement of foci and bone perforations.
Blood and fluid joint cultures isolated MRSA,and antimicrobial therapy was changed to intravenous vancomycin and maintained for two weeks.
Gradual improvement of symptoms and knee function was observed.The patient completed four weeks of oral antibiotherapy.
At one year of follow up the patient was asymptomatic,with preserved and painless mobility of the knee,and without recurrence of the infection.
There are several risk factors for MRSA infections identified,but can also happen in previously healthy children.
Several reports indicate that these infections in healthy children are increasing worldwide,however regional variations exist.
Correct surgical treatment of this infections with septic arthritis or acute osteomyelitisis is essential for a good outcome.

Van Neck-Odelberg disease is a benign skeletal abnormality of children involving a hyperostosis of the ischiopubic synchondrosis seen on radiographs.Differential diagnosis, such as stress fractures, osteomyelitis, tuberculosis,post-traumatic osteolysis, or any skeletal neoplasia,is need be ruled out to arrive at diagnosis.
Case report of 5-year-old girl that came to ER with complaints of letft groin with limp since 3 days.No swelling or raised local temperature was observed. White blood cell count and C-reactive protein was within normal range.
On X-ray sclerotic shadow was observed in ischiopubic region of a size of without any periosteal reaction or soft tissue shadows.MRI showed hyperintense signal on T2 with fat saturation, hypointense signal on T1 and swelling of the adjacent soft tissue.
The patient was treated conservatively with NSAID and strict bed rest for one week,following which patient was improved and had no symptoms on further follow-up visits after six months.
Diagnosis of Van Neck-Odelberg disease is a challenging diagnosis and clinical symptoms must be present.
Radiographic findings cannot be regarded as a diagnosis and some debate remains as to whether this is pathologic or a normal variant of the ossification process.
However radiographic changes in the ischiopubic synchondrosis due to infectious, neoplastic, or traumatic aetiologies have been described and may provide an additional diagnostic dilemma for clinicians.
ESR, CRP, wich have normal values, should be used to confirm the diagnosis. MRI can also provide considerable information to the clinician and can be considered to rule out other differentials and confirm the diagnosis.

Pyogenic sacroiliitis (PS) is a rare condition, representing 1% to 2% of all cases of septic arthritis.It occurs most frequently in children and young adults, with 200 cases reported in the literature.
Case report of a healthy 16- year-old boy who presented to ER with sudden onset of back pain radiating to the left lower extremity.The diagnosis was confounded by the presence of isthmic spondylolisthesis.Plain radiography demonstrated mild isthmic spondylolisthesis but no radiographic signs of tumour,trauma,infection,arthritis,or other developmental problems. The CPR level was 23 mg/L (N < 10 mg/L).Over the next 24 hours,the patient developed fever, and the CPR level increased to 233 mg/L. Sacroiliitis and an iliopsoas abscess were identified on MRI.In the blood cultures grew Streptococcus intermedius.
CT-guided percutaneous drainage of the abscess was performed, and the patient underwent 2 weeks of intravenous antibiotic therapy with excellent clinical and analytical response.He was then discharged, with 2 weeks of oral flucloxacillin + clindamycin.
The infection resolved without recurrence at 1 year.The patient recovered his previous functional status without restrictions.
The lack of specificity of clinical findings makes PS a condition difficult to diagnose.This case has the particularity of the atypical clinical presentation,initially without fever and with pain radiating to the left lower limb, and the incidental finding of IS at L5.
To our knowledge,there is only one other case report of PS caused by S intermedius in an adult reported in the literature.We report the first case of PS caused by S. intermedius in a paediatric patient.

Aneurysmal bone cyst (ABC) is a benign, expansile, non-neoplastic lesion of the bone, characterized by channels of blood and spaces that are separated by fibrous septae. ABC is a benign lesion, but malignant transformation has been reported in some cases. It can be difficult to handle because of the destructive effect on the bones and compressive effect on the nearby structures.
We report a case of a giant aneurysmal bone cyst in the proximal femur of a young child, which was treated with curettage and bone grafting with excellent clinical result after 10 years of follow-up.
A 4-year-old male patient, presented with slight pain in the left hip and sporadic gait claudication. There was no other significant contributing history. On local examination, there was tenderness on deep palpation of the left hip and restricted range of hip movements. Plain radiographs revealed a well-defined, expansile, lytic lesion involving the proximal portion of the left femur in the trochanteric and subtrochanteric region approximately 8cm x 4cm in size.
An MRI showed a hyperintense lesion in the proximal end of the shaft of the left femur on a T2-weighted image. It was a well-defined lesion, with some internal septations, without a periosteal reaction, cortical disruption or surrounding soft tissue abnormalities.
We performed, via mini-invasive lateral approach, a curettage and filling of the defect with
hydroxyapatite bone graft. He plays rugby without limitations or complaints. The bone graft was partially reabsorbed and bone ingrowth along the graft can be seen along anual follow up.

Femoroacetabular impingement (FAI) is a known cause of hip pain and decreased hip joint amplitude in young athletes.
One of the etiological factors for CAM-type FAI is proximal femur epiphysiolysis (PFE). In the literature, some cases of FAI in deformities with the characteristics of the PFE are described. Thus, PFE is thought to be a relatively common pathology with many undiagnosed subclinical cases.
Extra-articular impingement resulting from previous traumatic injury to the anteroinferior iliac spine (AIIS) is a rare cause of hip pain in the adolescent population. Currently, the recommended treatment for this type of pathology is arthroscopic decompression. However, hip arthroscopy is not universally available and requires an advanced and differentiated surgical technique.
We present the clinical case of a 15-year-old basketball player who presented at our consultation with complaints of pain in flexion and external rotation of the right hip. Imagiologically, she presented a CAM-type lesion compatible with PFE sequelae.
He underwent hip arthroscopy, and a rupture of the labrum and bone fragment of the AIIS (apparent fracture sequel) was found intraoperatively. Excision of the bone fragment was made, repair of the labral lesion with sutures with anchor and treatment of the CAM with lateral osteoplasty of the femoral neck.
Currently, the patient has 1 year and 3 months of follow-up. He has already resumed sports practice. It presents a slight pain in the internal rotation, without other limitations in the articular mobilization of the hip.

Osteochondritis dissecans of the patella is a rare pathology (<2%), assuming that the etiology may be related to the presence of patellar instability. It is characetrized by limited necrosis of subchondral bone that progresses slowly to separate osteocartilaginous fragments that then move freely in the joint. The results of the surgical techniques used in its treatment have a worse prognosis when compared to the other compartments of the knee.
Most studies in adolescents with osteochondral lesions (OCL) focus on classic lesions. Little is known about the results of the treatment of patellofemoral LOC.
Microfractures is often used as the first line of treatment since it is less invasive, has less morbidity, is technically less demanding and is cost-effective.
We present the clinical case of a 14-year-old girl, with bilateral gonalgia with 1 year of evolution characterized, with greater intensity on the right, triggered mainly with movements of going up and down stairs and associated with crackling. After a horse jump, her symptoms worsened, and she sought medical support. In complementary exams (MRI), a 10 cm Outerbridge Grade IV chondral lesion was observed in the central quadrant of the articular face of the right patella.
The patient underwent knee arthroscopy, with chondral stimulation performed with microfractures of the lesion and proximal alignment of the extensor apparatus (plication of the internal retinaculum and release of the external retinaculum).
After 5 years of follow-up, the patient shows a clear improvement in pain, being satisfied with the surgical result (IKDC improvement by 20 points).

Introduction: Tibia vara is a rare deformity and usually results from trauma with growth plate injury. Infections can also cause an early closure of the physis, with consequent instability, osteoarthritic changes and loss of limb function. Case presentation: 11-year-old male child with history of neonatal septic arthritis of the left knee, observed due to gait disorder and progressive left lower limb deformity in varus. The X-ray and CT scan showed a medial physeal bar of the proximal tibia with premature closure, MPTA of 70º and limb shortening of 4.7cm. He was submitted to curettage of the remaining physis, tibial infratuberositary and distal fibula osteotomies, and distraction osteogenesis with circular hexapod external fixator. The X-ray at 4 months showed signs of bone regeneration and the external fixator was extracted. After 6 months he presented a correct alignment with 1cm of limb shortening. He performed a physiotherapy program and return to sports without restrictions. Discussion: Different treatments are described for tibia vara, such as excision of the physeal bar, epiphysiodesis, chondrodiastasis or correction with external fixator. Our technique allowed a progressive and controlled correction of the axis with limited surgical exposure. Another advantage was restoring the limb length and its functionality at the same time. Conclusion: Surgical correction of major angulations using less invasive methods makes Ilizarov especially indicated in the treatment of tibia vara of different etiologies and complex deformities. In addition to providing greater stability, it allows to correct this type of deviation in a more controlled and accurate manner.

Introduction: post traumatic limp is a common reason for children’s hospitalization . many of these causes are not dangerous but require more serious treatment . one of the conditions is slipped capital femoral epiphysis(scfe) and requires emergency treatment . scfe is a condition of the proximal femoral physis that leads to slippage of metaphysis relative to the epiphysis . osteotomy performed at subcapital level plays a leading role in treatment of slipped capital femoral epiphysis(scfe) resulting in anatomical reduction. case report: A 5 years old male child was brought by his parents to hospital , with complaints of pain and difficulty in walking since 6 months . he had a history of fall from height and sustained injury to right hip. the pain was sudden in onset ,continuous and dull aching type . child was unable to squat or sit cross legged on floor . on physical examination , patient had antalgic gait with limb length discrepancy of 2cm with 1cm supratrochanteric shortening on right . passive and active range of movements of right hip was painful and limited , especially abduction and internal rotation . patient was evaluated radiologically by radiographs and mri . after complete evaluation , patient was operated by modified dunn osteotomy . patient was followed postoperatively and continued to have progressive improvement in his gait pattern and range of movements of hip joint . conclusion: In delayed presentation of scfe , modified dunn ostetomy has been shown to be an effective and safe alternative

Non-ossifying fibromas (NOFs) are common bone lesions affecting 20-30% of four to ten year olds. Despite this, they are rarely seen in clinical practice since they are commonly benign and asymptomatic lesions. Incidental findings on imaging can trigger further investigations, as clinicians may mistake NOFs for more sinister bone lesions such as aneurysmal bone cysts. However, these additional investigations and prolonged patient anxiety may be avoided if the lesion is correctly identified and staged using both plain radiograph and clinical information. We present a case series of 5 patients diagnosed with at least one NOF at Addenbrooke’s hospital. The aim was to identify the frequency and types of imaging used, highlighting NOFs’ morphological features and clinical characteristics to support clinicians in diagnosing and managing. Our cases illustrate the overuse of MRIs in the work-up of NOFs, thereby illustrating the need to increase awareness and knowledge of these common bone lesions.

Conradi-Hünermann Syndrome (CHS) is a form of non-rhizomelic chondrodysplasia punctata, inherited as an X-linked dominant trait. Ocular, cutaneous, cardio-respiratory and renal abnormalities have been reported; with a void in the general orthopaedic text describing skeletal manifestations. The hallmark feature of epiphyseal stippling on radiographs is due to enchondral bone formation. Growth retardation is commonly encountered, with disproportionate shortening of long bones. Though symptoms vary across a wide spectrum, Legg-Calvé-Perthes disease associated with CHS has not been reported before in the literature. A girl was born at term after an otherwise normal pregnancy. The child was noted to have brachydactyly of fingers and toes, with midface hypoplasia and flattening of the nasal bridge. Genetic studies confirmed the diagnosis of CHS. Right eye cataract and mild hydronephrosis were managed conservatively. There were shortening of the limbs and forearm asymmetry. After defaulting follow up for 3 years, the patient presented at 5years of age with mild pain over the left hip but was able to walk unassisted. Pelvic and left hip radiographs demonstrated destruction of the left capital femoral epiphysis, consistent with Legg-Calvé-Perthes disease. Although the symptoms of hip pain may be mild and easily overlooked in a child with multiple anomalies, intervention such as gait training to unload the hip is pertinent to delay progression of Legg-Calvé-Perthes disease early in the course of the disease. Rigorous surveillance in this group of patients may expand the clinical spectrum of CHS while reporting aids in better management of cases of infrequent occurrence.

Long bone fractures in newborns are uncommon during a traumatic delivery. Although the femur is fragile, neonate humerus fractures occur with a prevalence of 0.05 in 1000 labors.
 Diaphyseal humeral fractures represent less than 10% of pediatric fractures. Typically originate from labor difficulties, especially when the baby presents in the breech position. Obstetric maneuvers are necessary to urgently deliver the baby, sometimes provoking fractures in the process. Risk factors include fetal dystocia, prematurity, multiple gestations, and gestational diabetes. Breech delivery remains the most important factor, independently of the birth route.
 Overall, the prognosis for long-term is excellent. This case report is about a newborn who suffered left shoulder trauma during vaginal delivery from traction and rotation obstetric maneuvers.
 Deformity of the left arm and no active motion were present. Image study was conducted and a diaphyseal humeral fracture was diagnosed.
Conservative treatment was chosen and a coaptation splint immobilization was applied for two weeks. The excellent prognosis for conservative treatment is expected due to the intensive remodeling index of bone in the pediatric age. At reevaluation at 4 weeks, there was radiographic evidence of fracture union. Active range of motion was present without deficits.
Surgery remains indicated merely for polytrauma patients, open fractures, floating elbow, and cases of unacceptable angulation superior to 20°. Although diaphyseal humeral fractures in newborns are unusual and an anxious occurrence for parents, this case report shows how an orthopedic surgeon can be satisfied to apply a simple conservative treatment and expect excellent functional outcome.

Background: Supracondylar humerus fracture is the most common fracture around elbow in children. Closed reduction and percutaneous Kirschner wire (pin) fixation is the standard method of managing
displaced extension type supracondylar humerus fractures. The
configuration of wires is debatable. Although two crossed K-wires are mechanically stable, there is an
inherent risk of ulnar nerve injury. Lateral K-wires – parallel or divergent – are good alternative. This
study was aimed at identifying the best configuration for the lateral wires. Materials and Methods:
Patients with Gartland type 3 supracondylar humerus fractures were randomized by envelope method
to receive closed reduction and K-wire fixation in either a parallel or divergent fashion. The patients
were followed up at 3 weeks for wire removal and at 6 weeks and 3 months after surgery. Baumann’s
angle, functional outcome as per Flynn’s criteria, and range of motion were recorded in each visit.
Effect of delay in surgery was also evaluated as a secondary outcome. Results: Nineteen patients
received fixation with parallel wires and 11 patients had divergent fixation. No loss of reduction was
seen in any patient at 3 months. No statistically significant difference was seen in the Baumann’s angles
and outcome according to Flynn’s criteria irrespective of the wire configuration (divergent or parallel).
Furthermore, the delay in surgery was also found not to have a significant effect on the functional
outcome. Conclusions: Both parallel and divergent K-wire configurations provide satisfactory stability
when accurate reduction and adequate fixation of the fracture has been done.

Introduction: Cerebral Palsy (CP) is a non-progressive upper motor neuron disease due to injury to the immature brain and is one of the commonest neuromuscular disorders seen in children. As age advances, this disorder can lead to loss of muscular balance with a mixture of spasticity and contracture of affected joints. Materials and methods: This is a study of 177 CP patients treated by us from January 2004 to December 2020. There were 105 male and 72 female. Their age ranged from 2 to 49 years. The common presentation was spastic gait. Scissoring and equinus are common deformities in lower limb and pronation and wrist flexion deformity in the upper limb. Lower limbs were operated in 141 patients and upper limb in 39. Surgical procedures included soft tissue release, tendon transfer, corrective osteotomy and arthrodesis. 42 patients who presented with rigid deformities were treated with Ilizarov external fixator. Results: 21 patients were lost in follow up. All patients improved significantly. Discussion: CP is quite common in developing countries like India due to poor socio-economic conditions. Surgical treatment indicated when deformities and/or contracture interfere with activities of daily living. In early stages, most of the deformities and contracture can be corrected with soft tissue release to tendon transfer. At a later stage when deformities are rigid, they can be safely corrected with Ilizarov Fixator. The results were better in younger patients. It is concluded What surgery can achieve in hours, physiotherapy cannot in years.

Traumatic cervical spine injuries in children are rare. Interpretation of cervical spine radiographs and clinical examination in children can be difficult. In childhood, the cervical spine presents variations of normality that must be known so that they are not interpreted as pathological, especially in a traumatic context, avoiding exposure to more radiation. The aim is to show a physiological radiological finding of the infantile cervical spine that tends to be misinterpreted as pathological: Pseudosubluxation C2-C3. A 30-month-old infant with head and neck trauma after a swing fall, resulting in headache and cervicalgia. The mother denied syncope, nausea or vomiting. He presented pain on palpation of the spinous processes and paravertebral of the cervical spine, without neurological compromisse. In lateral cervical spine radiograph showed a subluxation C2-C3, without fracture. He was immobilized with a cervical collar and a computed tomography was requested, which showed C2-C3 subluxation, with adequate alignment of the posterior wall and loss of cervical lordosis. He was re-evaluated early, he was asymptomatic, the control X-ray showed normalization of cervical lordosis and the absence of injury was confirmed. It is important to know the Swischuk line in the radiographic study, which may be sufficient in the initial evaluation. However, in view of the possibility of acute cervical spine injury, computed tomography should be considered. A multidisciplinary consensus should be established.

Slipped capital femoral epiphysis is one of the commonest musculoskeletal disorders amongst children. Whilst its management is reasonable well established, the treatment of the unaffected contralateral hip is controversial. The incidence of subsequent contralateral slip has been reported to be between 19% and 63%. The two treatment modalities are prophylactic fixation at initial presentation or active surveillance and fixation on diagnoses of subsequent slip. Both approaches have their merits but there is no clear consensus. Known risk factors include age, sex, young age at initial presentation, endocrine disorders and obesity. Clinical, epidemiological and radiological predictors have been assessed retrospectively but have limited prospective accuracy. We performed a systematic review of the existing literature as per PRISMA guidelines to determine which treatment modality is more effective. Qualitative analysis of the literature also yielded interesting insights into different aspects of the management of the contralateral hip in unilateral SCFE.

Proximal femur fractures (PFF) in children are rare (< 1%) and usually the result of an high-energy trauma. They are classified into 4 types based on the anatomic location of the fracture, as described by Delbet and Colonna. This classification is widely accepted and is used to determine the treatment and prognosis. Hip spica casting should be used in most children’s hip fractures (in addition to internal fixation) to immobilize the extremity and allow complete and solid fracture healing. The major complication is AVN, being his best predictor the displacement of the fracture at the time of injury. Results in younger children (<8-year-old) with nondisplaced fractures or type III or IV fractures are better than those in older children with displaced type I or II fractures. Internal fixation devices should be kept distal to the physis; however, fracture stability is of prime importance and should not be compromised in an attempt to avoid the growth plate. The authors present 2 clinical cases of PFF. The first one of a 6-year-old girl with a left PFF Delbet type IV that underwent ORIF with a pediatric SHS.
The second case of a 5-year-old boy with a left PFF Delbet type III that underwent CRIF with 2 cannulated screws, and imobilization with an one-and-one-half-hip spica cast. In both cases surgery and the postoperative period were uneventful. In the follow up appointments both had good results according to Ratliff criteria (no hip pain, ROM complete, simmetrical and painless, and no signs of AVN)

Introduction: American football is well known for high rates of traumatic brain injury among players. There is a lack of nationwide analyses assessing incidence of concussion requiring hospitalization, outcomes, and associated risks. Methods: The Kid’s Inpatient Database was queried for American football sports injuries from 1997-2012, including concussions. Patient characteristics and hospitalization outcomes were investigated. Significant changes in annual concussions, and assessments of concussion patient characteristics relative to non-concussion patients were elucidated using chi-square analysis and independent samples t-tests. Results: 3453 American football injuries were isolated. 333 (9.6%) players were admitted for concussion, and annual concussions decreased from 9.5% (81/856) in 2009 to 7.3% (252/2598) in 2012. Relative to average admission for a football related injury, patients with concussion were less likely to have elective admission (3.3% vs 10.4%, p<0.001), a shorter length of stay (1.2 vs 2.4 days, p<0.001), and lower total charges (18,466.68 vs 29,751.89). Concussion incidence was higher among patients with attention deficit and hyperactivity disorder ([ADHD] 15.9% vs 9.4%, OR=1.8 [1.1-2.9], p=0.013). Concussion incidence was higher among adolescents (>12) relative to children (5-12) (10.6% vs 6.4%, OR=1.8 [1.3-2.4], p<0.001, respectively). Conclusion: Annual concussions among hospitalized football players decreased in recent years. Adolescent players and players with ADHD were more likely to be admitted with a concussion.

Paediatric distal radius buckle fractures are common, but their management remains controversial. The use of forearm cast is widespread and the usual treatment option. There is still debate over the use of rigid or soft casts, the duration of the immobilisation or the need for serial radiographs and follow-up in the outpatient clinics. We retrospectively studied 36 consecutive children with a mean age of 7.86 years (range 1-16) with buckle fractures of the distal radius, presenting to our fracture clinic during the first wave of the COVID-19 pandemic. 19 (52.7%) patients were treated in an above elbow cast and 1 has been initially treated in an above elbow cast which was later converted to a below elbow cast. Only 5 (14%) patients were provided with a soft cast and clear guidance to the parents for removal of the cast and telephone follow up. The patients were immobilised for a mean time of 4.1 weeks (range 2-6 weeks). 3 of the 31 patients who returned to clinic for a cast removal, have also had a check radiograph. We can conclude that the management of these fractures remained controversial even in a small trauma unit during the pandemic when clear national guidelines were published. There is clearly a need to establish a protocol in our department which would reduce unnecessary follow-up visits and could save resources without a compromise of the patient outcome. Discussion and clear explanation to the parents of the clinical management and potential outcome would ensure high satisfaction rates.

A 12-year-old boy was treated conservatively for symptoms of appendicitis and sore throat in another hospital. Later swelling and fistulation occurred above the left clavicle. Scintigraphy, X-ray, MRI and histology verified osteomyelitis. Systemic antibiotic therapy was ineffective. Two months later the swelling and pain still existed, the excretion decreased, but the fistula was still open. The patient had fever. He was transported to our hospital where wide osteotomy and aggressive debridement were performed. An antibiotic bead chain was left in the clavicle for two weeks. The deltotrapezoid fascia and the skin were adapted. Systemic antibiotic therapy was given according to bacterial culture. After two weeks the wound healed, inflammatory laboratory parameters normalized. Another surgery was performed. The antibiotic chain was removed, the bone was filled with resorbable beta-tricalcium phosphate granulate. The osteotomy was closed using interfragmentary screws. The clavicle healed and screws were removed after 10 months. Bone infections must be treated surgically. Devitalized bone fragments and dead space provide a hotbed for bacteria. Careful debridement, effective topical and systemic antibiotic therapy are crucial for successful treatment. Antibiotic bead chains decrease the cavity in the bone. High antibiotic concentration is ensured for two to three weeks. Early revision, synthetic bone complement and stable osteosynthesis facilitate healing process.

Background: Osteogenesis imperfecta (OI), also known as brittle bone disease, is a rare and clinically heterogenous genetic connective disorder. It manifests mainly as bone fragility resulting in increased susceptibility to fractures, deformities, and substantial growth abnormalities. It is commonly caused by autosomal dominant heterozygous mutations in one of the two genes encoding type I collagen, COLIA1 and COLIA2. Bisphosphonates (BP) have been considered standard of care for children with severe OI. Case Presentation: A 27-year-old man with OI (history of multiple fragility fractures since early childhood) presented at emergency department due to pain in right knee, after direct trauma due to falling from is bicycle. At physical exam showed swelling, pain with mobilization and functional limitation.
The patient performed x-ray, presenting proximal tibia fracture and surgical treatment was performed with open reduction and internal fixation. At the x-ray, it also can be seen five metaphyseal bands of increased density paralleling the contours of the physis in the distal femur, proximal tibia and fibula, and distal tibia. Clinical Outcomes: These metaphyseal bands, also described as zebra stripe sign, are radiological manifestation of cyclical bisphosphonate therapy prior to closure of epiphyseal growth plates and are seen in 50 % of the patients. Usually they develop after about two months of BP therapy and are probably due to the establishment of a new balance between osteoblastic and osteoclastic activities. Therefore, these sclerotic lines are due to increased bone formation and temporary interruption of growth plate cartilage absorption induced by BP.

Background: In spinal muscular atrophy (SMA) the most challenging orthopedic procedures are the surgical treatment of scoliosis and hip dislocation. Pelvic obliquity suggests casual relationship between these two conditions. Case presentation: We report a 10 year old girl with SMA type III who developed right-convex thoracic (RCT) and left-convex lumbar (LCL) spine curves along with left pelvic tilt when standing and walking. Standing AP spine X-ray image showed 28 and 31-degree RCT and LCL curves respectively without any rotational deformity. Interestingly, on the sitting plain radiographs however these changes were less noticeable. During physical examination left hip instability was observed. Gait analysis revealed limited elevation of the left lower limb during the swing phase and remarkable rotation of her left hip in terminal swing and stance. The logical approach of lengthening the left lower limb with heel elevator for the purpose of levelling the pelvis and thus correcting spine curves was found to have an adverse effect on the condition. Instead, capsule reefing and Pemberton procedure were chosen for the stabilization of the hip, which eventually led to the decrease of the functional scoliosis. Discussion: Our patient consistently tilted her pelvis to prevent left hip dislocation in upright position which resulted in secondary spinal curvature. In sitting position however this hip stabilization manoeuvre was unnecessary, consequently scoliotic curves were not seen. Conclusion: We hypothesize that in neuromuscular disorders with hypotonic muscle condition hip stabilization surgery might be superior to spinal deformity correction.

Background: Joint subluxation and dislocation can occur in poorly managed or uncontrolled rheumatoid arthritis. This can occur in the small joints of the hands and feet. However, atraumatic dislocation of larger joints is rare. Literature has shown one case of an atraumatic hip dislocation in a 61-year-old woman. There are no documented cases of these occurring in children. Cases: Two unrelated young girls (aged 9 and 11 years) with a history of juvenile rheumatoid arthritis (JRA) were referred. Both were diagnosed with JRA at the age of 2. Both were treated with disease modifying anti-rheumatic drugs (DMARDs) and had intraarticular steroid injections to treat ongoing right ankle pain. Patient A presented with an anterior dislocation of the tibiotalar joint with a dysplastic tibial plafond. Examination under anaesthesia proved an irreducible dislocation. The dislocation was treated sequentially with a Taylor Spatial frame to reduce the ankle and then osteotomy with plate fixation. Patient B, with right ankle anterior subluxation, was treated with a distal tibia opening wedge osteotomy which corrected the deformity. Both patients had good outcomes from surgery. Discussion: It is rare to have joint dislocations in JRA that is well controlled. There have been no cases in the literature of atraumatic ankle dislocations in children. It is unclear if this is the sequela of the disease process or secondary to repeated steroid injections. Conclusion: Atraumatic joint dislocations are rare and unheard of in the pre-pubescent age group. We highlight these cases to inform the reader of this unusual presentation.