INTRODUCTION:Radial polydactyly reconstruction requires procedures that achieve both functional and aesthetic outcomes. When both duplicates are of similarly small diameters, a combination procedure may be necessary. Furthermore, primary surgical alignment is crucial to ensure a straight thumb and avoid future deviations. This study evaluates the modified Bilhaut-Cloquet procedure for the reconstruction of Wassel-Flatt types IV-VII radial polydactyly in paediatric patients. METHOD:The study included 22 patients aged 6-60 months. Inclusion criteria include similar-sized duplicated thumbs that meet nail criteria (<70% of a normal contralateral thumb), necessitating a combination procedure in order to create a functional and aesthetically pleasing single thumb. Patients were followed for an average of 14.5 months. Outcomes were assessed using a visual analogue scale for satisfaction (0-10), nail width and girth measurements, and the Tada scoring system for function and cosmesis. RESULTS:All the flaps survived. The reconstructed thumbs had near-normal size, contour, and alignment. Five cases showed mild nail ridges without any severe deformities. The average nail width and girth were 97 and 96% of the values for the contralateral thumb, respectively. The mean visual analogue scale score was 8.9, indicating high patient satisfaction. The median Tada score was 4.7, with 15 excellent and seven good cases. CONCLUSION:In Wassel-Flatt type IV-VII radial polydactyly with both duplicates exhibiting smaller nail diameters, a combination technique using the modified Bilhaut-Cloquet procedure results in good appearance and function. Meticulous attention to detail can reduce the risk of complications, including nail deformities and flap loss. LEVEL OF EVIDENCE:IV.

Pediatric polydactyly is a relatively common congenital condition of hand and foot, affecting physical and mental development of children. Hand polydactyly has been brought into focus recently. By contrast, the studies on foot polydactyly are limited. Among the types, there is little international research on preaxial foot polydactyly since it is a relatively rare type, and the domestic research on it is fewer. The purpose of our study is to propose a new classification for guiding operation. We collected all patients with preaxial foot polydactyly who had preoperative radiographs at our hospital between 2016 and 2024, and analyzed the reported classifications, finally proposed a new classification system based on the preoperative radiographs. The 64 feet were assessed by 5 observers under the help of the kappa statistic. We operated the derived surgery on various types of the classification system, and evaluate the therapeutic efficacy through the relative imaging parameters and scale. We developed a combined classification system for preaxial foot polydactyly, describing variation of hallux in longitudinal dimension. In this classification system, we concluded duplication of distal phalanx combined with abnormal/ normal proximal phalanx, duplication of proximal phalanx combined with abnormal/ normal proximal phalanx or metatarsal, duplication of metatarsal combined with abnormal proximal phalanx and duplication of tarsal. Overall inter-observer agreements for this classification system respectively were 0.805 and 0.795 in first and second reading and intra-observer agreements for 5 observers were > 0.9. Under the derived surgery, the scale for the hallux with preaxial foot polydactyly exhibited notable improvement. The proposed new classification effectively show different features of all categories, the reliability of which was proved good. The derived surgical strategies of the combined classification system improved the surgical outcomes significantly, which can effectively correct hallux varus and prevent hallux valgus to some extent.

INTRODUCTION:Although radial polydactyly is a common congenital hand malformation, its co-occurrence with thumb hypoplasia is rare, as the two are seen as opposite ends of a developmental spectrum. Radial polydactyly with thumb hypoplasia poses a significant diagnostic challenge, often leading to under-recognition and -treatment of the hypoplastic component. This study reviews our experience with the comprehensive management of this complex association. METHODS:This retrospective study reviewed 13 cases (11 males) with a mean age of 28.2 months. Radial polydactyly with thumb hypoplasia cases that presented between 2017 and 2024 were reviewed. All patients underwent a tailored surgical strategy based on the Wassel classification and Blauth grade of hypoplasia in either single or two-stage procedures. RESULTS:The majority of patients were classified as Wassel VII, and the most common thumb hypoplasia grading was Blauth II. At follow-up (13-88 months), reconstructed thumbs exhibited favourable aesthetics and functional opposition. Using the Japanese Society for Surgery of the Hand ratings, four patients were rated excellent, seven were rated good, and two were rated fair. Kapandji scores ranged from 6 to 9. CONCLUSION:Optimal outcomes in preaxial polydactyly require a high index of suspicion for potential thumb hypoplasia, even in its subtle forms. A comprehensive surgical plan that integrates the correction of both anomalies is fundamental to achieving reliable functional and aesthetic outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE:Therapeutic IV.

Purpose:Perioperative pain management in children with Gartland Type III supracondylar humerus fractures (SHF) is crucial but often inadequately addressed, leading to significant pain experiences. This study aimed to evaluate the efficacy and safety of coracobrachialis plane musculocutaneous nerve block (Cora-MNB) compared to supraclavicular brachial plexus block (SC-BPB) for analgesia in pediatric Gartland Type III SHF patients. Methods:A prospective pilot study enrolled 105 pediatric patients with Gartland Type III SHF was performed. Primary outcome was the postoperative FLACC scale measured at 12 h postoperatively. Secondary outcomes included FLACC scale measured at 1 h, 6 h and 24 h postoperatively. They also included postoperative thumb and shoulder strength, opioid use, NSAIDs use, length of hospital stays, patient satisfaction, surgeon satisfaction, operation time and puncture channels. One hundred and five patients were randomized allocated between groups. Results:Patients receiving Cora-MNB showed superior analgesia, with median postoperative FLACC pain scores at 12 h reduced by 40% [Cora-MNB: 3.00 (2.00) vs. SC-BPB: 5.00 (2.00), ***p < 0.001]. Thumb extensor weakness incidence decreased significantly (Cora-MNB: 13.5% vs. SC-BPB: 84.9%, ***p < 0.001). Shoulder mobility preservation was achieved in 98.08% of Cora-MNB cases vs. 20.75% with SC-BPB (***p < 0.001). While opioid consumption showed no intergroup difference, Cora-MNB reduced NSAID rescue times [Cora-MNB: 0.00 (1.00) vs. SC-BPB: 1.00 (1.00), **p = 0.0014]. Procedure duration favored Cora-MNB [4.54 ± 1.21 (min) vs. 9.02 ± 1.94 (min), T = 14.32, 95% CI: 3.88-5.12, ***p < 0.001], with higher surgical and parental satisfaction scores. Hospital stays remained comparable [1.60 ± 0.66 (days) vs. 1.56 ± 0.67 (days), p = 0.98]. Conclusion:Cora-MNB proves to be a safe and effective approach for anesthesia in pediatric SHF cases, offering superior analgesic outcomes, reduced NSAIDs usage, improved shoulder functionality, and high satisfaction levels without extending the hospital stay. This study supports the implementation of Cora-MNB as a valuable technique in perioperative pain management for pediatric SHF patients.

INTRODUCTION:Wassel type III thumb polydactyly is characterized by a bifid proximal phalanx. Although a relatively rare subtype, it is considered one of the most challenging types to reconstruct as often the distal duplication requires some form of combination procedure for optimal aesthetic outcomes. METHODS:A retrospective review of 94 patients with Wassel type III thumb duplication analysed patient characteristics, radiographic features, surgical techniques, and outcomes. A modified classification was designed based on the osseous morphological patterns and interphalangeal (IP) joint stability. Subtype III-A showed similar combined proximal phalangeal and metacarpal head widths with narrow inter-duplication distance; subtype III-B showed a wider proximal phalanx with unstable IP joint; subtype III-C showed a wider proximal phalanx (A > B) with a stable IP joint; and subtype III-D showed divergent alignment at the metacarpophalangeal joints and convergence at the IP joints. RESULTS:The median age at surgery was 15 months with a median follow-up of 36.5 months. Optimal results were observed with these surgical techniques: a modified Bilhaut-Cloquet (BC) procedure for the distal and distal-proximal phalanges in subtype III-A and III-B, respectively; minor thumb resection with reattachment of the abductor pollicis brevis and collateral ligament for subtype III-C; and reconstruction similar to Wassel type IV-D for subtype III-D. Postoperative thumb deviation correlated with mismatched surgical techniques. Minor nail ridging after the modified BC procedure diminished over time. CONCLUSION:This study proposes a subtype classification and surgical algorithm to guide management of Wassel type III thumb polydactyly to produce optimal aesthetic and functional results. Future prospective multicenter studies with standardized outcome measures are needed to validate these findings and optimize surgical protocols. LEVEL OF EVIDENCE:IV.

PurposeThis study aimed to investigate the relationship between the ratio of c-reactive protein to albumin (CAR) and pediatric septic arthritis (PSA).MethodsClinical and laboratory data were collected. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive ability of CAR in identifying PSA. Multivariable logistic regression analyses was performed to calculate adjusted odds ratio (OR) with 95% confidence interval (CI).ResultsWe included 305 patients with PSA (CAR ≤ 0.447, 182 patients; CAR > 0.447, 123 patients) between September 2013 and November 2022. ROC analysis showed that CAR performed best in diagnosing PSA, with an area under curve (AUC) value of 0.828. After adjusted for potential confounders, we found that high CAR was associated with PSA (OR = 6.85, 95% CI: 2.30–20.40, p = 0.001). In sensitivity analyses, subgroups analyses, and propensity score matching, the results remain stable.ConclusionsThe CAR (>0.447) at admission was an independent risk factor for PSA. It is worthy to further investigate this association.

BACKGROUND:The authors report the techniques and results of contiguous dorsal cross-shaped advancement flaps for reconstruction of 3- or 4-finger syndactyly in a single-stage operation for congenital syndactyly. METHODS:Thirty-five patients with multiple-finger syndactyly who received webspace reconstruction using the contiguous dorsal cross-shaped advancement flaps in a single operation were retrospectively studied. The patients ranged in age from 5 to 96 months (average age, 29.6 months). The contiguous dorsal cross-shaped flaps were advanced to reconstruct both webspace and lateral walls of the bases of the conjoined fingers. Withey grading was used for postoperative evaluation of web creep. Scar hyperplasia was assessed using the Vancouver Scar Scale. A visual analog scale of 0 to 10 was applied to evaluate the subjective satisfaction of the parents. RESULTS:In all cases, the syndactyly was successfully released in a single operation. There were no perioperative complications in this group. During a 12- to 58-month follow-up period, all reconstructed webspaces exhibited satisfactory appearance, and there was no obvious web creep. The dorsal hand scars were acceptable. Revision surgery was not needed in any patient. The average web creep was 0.45, and the average Vancouver Scar Scale score was 1.6. The average visual analog scale score for appearance was 1.2, and that for function was 2.5. CONCLUSIONS:Multiple syndactyly release in 1 stage is feasible and safe. The contiguous cross-shaped flaps can be used to reconstruct 2 or more webspaces simultaneously after releasing. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

Background and objective:The use of sizable dorsal flaps for webspace reconstruction without skin grafting can minimize complications in syndactyly correction. We report the technique and results of a cross-shaped advancement flap for reconstruction of the webspace and coverage of the lateral sides of the bases of the separated fingers in congenital syndactyly. Methods:From June 2018 to July 2020, 15 patients with simple or complex syndactyly for webspace reconstruction with a dorsal cross-shaped advancement flap were retrospectively studied. The patients' ages ranged from 5 to 144 months, with a median age of 12 months. Out of these 15 patients, six patients were suffering from bilateral involvement. Withey grading of web creep was used for postoperative evaluation. Scar hyperplasia was assessed using the Vancouver Scar Scale, and Visual Analogue Scale was applied to evaluate the subjective satisfaction of the children's families with the reconstructed finger appearance, pain and function. Results:There was no perioperative complication in the group. During an 8-17 months follow-up period, no secondary correction was needed in this group. The average score of Withey scale was 0.1, and Vancouver Scar Scale was 1.5. The Visual Analogue Scale score of appearance, pain and function was 1.8, 0.2 and 1.1, respectively. Conclusion:This technique can reconstruct the webspace and cover the lateral wall of the fingers for syndactyly correction without the risk for web creep or hypertrophic scar.

We report the application and results of skin defect coverage using the free lateral great toe flap in revision surgery for residual postoperative deformities in Wassel-Flatt type IV-D thumb duplications. This retrospective study included five patients treated between June 2020 and September 2021 to correct angular deformity and repair the secondary skin defect. All the flaps survived. The patients were followed up for 8-12 months and all the reconstructed thumbs had a satisfactory appearance. The results of the Japanese Society for Surgery of the Hand scoring system were excellent in one patient, good in three patients and fair in one patient. The results of the Alignment, Ulnar and Radial stability, Range of motion and Aesthetical aspects (ALURRA) scoring system were good in four patients and moderate in one patient.Level of evidence: IV

Purpose: To present a surgical technique of combining the on-top plasty with modified Bilhaut-Cloquet procedure for reconstructing a rare type of complicated radial polydactyly and evaluate the outcomes. Methods: Fourteen complicated radial polydactyly in 13 patients were corrected by combining the on-top plasty with modified Bilhaut-Cloquet procedure. Osteotomies were performed as required, and the acral part of the ulnar thumb was transposed onto the proximal part of the radial thumb. The distal parts of the two thumbs were isolated as neurovascular pedicled composite tissue flaps, including part of the distal phalanx and nail bed, and were attached together in an extra-articular way. The tendons were rebalanced, and the nail bed was re- constructed. Objective and subjective outcomes were assessed. Results: The average follow-up time was 32.4 months (6-60 months). All reconstructed thumbs were rated as good in appearance and function. The mean Vancouver Scar Scale score was 1.3 (range 1-2) and the mean Wang-Gao score of the reconstructed thumbnail was 9.4 (range 8-11). The Tada score for the function of the reconstructed thumb was 5.5 (range 5-6). The main

Synpolydactyly is one type of complicated syndactyly characterized by a combination of central polydactyly and syndactyly mostly affecting the middle and ring fingers. 1 Kuru I. Samli H. Yucel A. et al. Hypoplastic synpolydactyly as a new clinical subgroup of synpolydactyly. J Hand Surg Br. 2004; 29: 614-620 Crossref PubMed Scopus (13) Google Scholar Owing to variable and progressive deformities of synpolydactyly, the multiple-finger syndactyly, lateral deviation of the affected digits, tendon and neurovascular abnormalities, side-to-side skeletal union, and irregular phalanges may exist in a hand concurrently, which lead to a great challenge in surgical reconstruction. Generally, two or more stages are regularly suggested to avoid vascular insufficiency of the skin flaps or digits and shortage of skin by most authors, especially when more than two digits are conjoined. 1 Kuru I. Samli H. Yucel A. et al. Hypoplastic synpolydactyly as a new clinical subgroup of synpolydactyly. J Hand Surg Br. 2004; 29: 614-620 Crossref PubMed Scopus (13) Google Scholar ,2 Kozin S.H. Zlotolow D.A. Common pediatric congenital conditions of the hand. Plast Reconstr Surg. 2015; 136: 241e-257e Crossref PubMed Scopus (33) Google Scholar In this short communication, we described our experience in reconstructing the synpolydactyly with three-finger syndactyly by using contiguous dorsal advancement flaps to rebuild web spaces in a single stage.

Purpose The aim of the study was to present the intraoperative findings of the relevant digital nerves of the duplicated thumbs in an excision and reconstruction procedure for the Methods The study was conducted on patients with Wassel-Flatt type IV radial polydactyly who underwent excision and reconstruction between 2018 and 2021 atour institution. The ulnar digital nerve of the radial thumb and the radial digital nerve of the ulnar thumb were identified and traced intraoperatively. The level of the bifurcation of the nerves and abnormal findings were documented. Results A total of 123 hands in 119 patients were included in this study. In 114 hands, the bifurcation of the nerves was located within 1 cm of the metacarpophalangeal flexion crease. The radial digital nerve to the ulnar thumb was abnormally compressed in deep fascial tissue in 7 of these 114 hands. In 5 hands, the level of bifurcation was more than 1 cm proximal to the crease. No radial digital nerve to the ulnar thumb was identified in the remaining 4 hands. Conclusions Although rare, abnormal nerve compression of the digital nerve may exist in duplicated thumbs of Wassel-Flatt type IV radial polydactyly. Clinical relevance In an excision and reconstruction procedure, we suggest that the bifurcation of the nerves should be identified before the nerve to the radial thumb is excised to avoid injuring the nerve to the main ulnar thumb. (J Hand Surg Am. 2023;48(11):1169.e1-e6. Copyright (c) 2023 by the American Society for Surgery of the Hand. All rights reserved.)

Objective:To explore the efficacy of closed reduction using "three-men method" and percutaneous pinning for type Ⅳ pediatric supracondylar humeral fractures.Methods:Clinical data were retrospectively reviewed for 145 children with type Ⅲ/Ⅳ supracondylar humeral fractures undergoing operations from January 2016 to November 2019. They were divided into two groups according to the fracture classification. Twenty-six children with type Ⅳ supracondylar humeral fractures were selected as group A, including 19 boys and 7 girls with an average age of 5.5 years. Involved side was left (n=12) and right (n=14). And 119 children with type Ⅲ supracondylar humeral fractures were assigned into group B, including 84 boys and 35 girls with a mean age of 5.4 years. Involved side was left (n=73) and right (n=46). Age, gender, fracture time, operative duration and Kirschner wire fixation method were recorded along with postoperative needle-path infection, fracture healing, nerve injury recovery, postoperative Bowman angle, loss of carrying angle and elbow range of motion. Postoperative functional recovery was assessed by the Flynn scoring criteria of elbow joint function.Results:None had any postoperative onset of cubitus varus, nonunion, myositis ossificans or Volkmann ischemic contracture. The excellent/good rate of postoperative carrying angle and elbow range of motion according to Flynn score was 96%. There were no significant inter-group differences in age, gender, sideness of injury or fracture time. Operative duration in group A was longer than that in group B [ (36.3±13.8 ) vs. (31.3±13.8) min] and the difference had statistical significance ( P=0.032 ) . The probability of using the third/fourth Kirschner wire was higher in group A than that in group B [46.2% (12/26) vs. 27.7% (33/119) ] and the difference had statistical significance ( P=0.01 ) . The average fracture healing time was 4.6 weeks in group A and 4.4 weeks in group B. No significant inter-group difference existed in fracture healing time ( P=0.105) . There were no significant inter-group differences in pin tract infection rate, elbow range of motion, Bowman angle, loss of carrying angle or whether or not extension line of anterior humeral line passing through capitellum ( P>0.05) . Conclusions:For type Ⅳ supracondylar humeral fractures in children, closed reduction and percutaneous Kirschner wire fixation may achieve similarly satisfactory outcomes to the same method for type Ⅲ supracondylar humeral fractures.

This article reported a case of a rare disease patient with Proteus syndrome. The 10-year-old male who presented with a 5-year history of mass on left heel and a 3-year history of mass on the toes of left foot, presented to Beijing Jishuitan Hospital in July 2018. Multiple lipomas on the heel of the left foot, the end of the foot was enlarged like a hammer. The skin at the bottom of the foot showed linear verrucous epidermal nevi. Superficial vein malformations of both feet and calves. He underwent left toe mass resection in Beijing Jishuitan Hospital. Pathological results: synovial tissue hyperplasia and cartilage metaplasia. Collagen fibers show tumor-like hyperplasia. The patient had a mutation (c.49G>A, p. Glu17Lys) in the oncogene AKT1. Pathological and genetic test results support the diagnosis of Proteus syndrome. Followed up was performed after operation for 24 months, the condition was well controlled.

目的:探讨非特发性早发性脊柱侧凸(EOS)的Mehta石膏矫形治疗效果.方法:回顾性分析2014年10月-2019年10月在本中心就诊并进行石膏治疗的有完整影像资料11例非特发性EOS患儿.全部患儿均于治疗开始前拍摄站立位全脊柱X线片,并在石膏矫形治疗1个月后再次拍摄站立位全脊柱X线片,测量EOS冠状面(Cobb角)和水平面(RVAD).采用配对样本t检验比较治疗前后的影像学资料及治疗效果.结果:得到随访的11例患儿,麻醉下Mehta石膏治疗5例,共7次,先天性2例,神经肌肉型1例,神经纤维瘤病1例,脊髓疾病1例;非麻醉下Mehta石膏治疗6例,共7次,先天性2例,神经纤维瘤病3例,神经肌肉型1例.麻醉下Mehta石膏组有1例拆除石膏后发现背部皮肤压疮,换药后愈合,非麻醉下Mehta石膏组未见有石膏压疮.患儿经过1个月Metha石膏矫形后平均Cobb角较术前明显降低,差异有统计学意义(P<0.01).与术前相比较,术后RVAD较术前有明显下降,差异有统计学意义(P<0.01).结论:初步结果显示Mehta石膏可有效控制非特发性EOS冠状面和水平面畸形.

Background: The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescents commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis and treatment of this complex fracture pattern. Methods: The charts and radiographs of six patients were reviewed. The function was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results: The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. Talar subluxation laterally with medial space widening in three, and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6-8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions: Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

目的:探讨小儿股骨干骨折患儿采用桥式钢丝夹板外固定治疗的临床疗效.方法:采用随机数字表法将60例小儿股骨干骨折患儿均分为两组,试验组30例给予桥式钢丝夹板外固定治疗,对照组30例予以Bryant牵引术治疗,对比两组的治疗效果.结果:试验组治疗优良率为96.67％,与对照组的93.33％对比,差异不显著(P＞0.05);两组骨折愈合时间对比,差异不显著(P＞0.05);试验组不良反应发生率为13.33％,较对照组的36.67％减少,差异显著(P＜0.05).结论:对于小儿股骨干骨折患儿,采用桥式钢丝夹板外固定治疗,疗效确切,不良反应少,治疗安全,有临床推广价值.

Objective To compare the curative effect and complications of separable patella claws and tension-band wire with Kirschner wire tension band in the repair of children comminuted patellar fractures.Methods A total of 68 children with comminuted patella fracture treated in our hospital from January 2012 to January 2015 were randomly selected and randomly assigned to observation group and control group,34cases in each group.Observation group received separable patella claws and tensionband wire fixation.Control group received Kirschner wire tension band fixation.Operative time,incision length,fracture healing time,postoperative complications and Hospital for Special Surgery knee function scores were compared between the two groups.Results No significant difference in incision length [(51.54 ± 4.13 vs 52.09 ± 3.82) min] and operative time [(6.92 ± 0.12 vs 6.93 ± 0.14) cm] was detected between the two groups (P ＞ 0.05).Significant differences in healing time [(9.04 ± 1.05 vs 10.88 ± 0.92)w],incidence of complications and The excellent and good rate of knee joint function treated in observation group(91.18％)was higher than control group(70.59％),and the incidence of complications was lower than control group (2.94％ vs 20.59％),the difference was indicated significant (all P ＜ 0.05).Conclusion Separable patella claws and tension-band wire in the repair of children comminuted patellar fractures has some advantages such as short healing time,good functional recovery of knee joint and less postoperative complications,has good prospects.