Objectives: The purpose of this study is to discuss the natural history and management of primary epiphyseal osteomyelitis (PEO), to differentiate clinico-radiologic features of PEO caused by Mycobacterium and other organisms, and to discuss their intermediate-term outcomes. Methods: Between 2006 and 2017, 18 patients of PEO were managed at our center. Blood investigations, x-rays, and magnetic resonance imaging of affected part were carried out. Surgical drainage of lesions was done to retrieve infective fluid and tissue for examination. Antibiotics were administered for 1 year in Mycobacterial PEO and for 6 weeks in bacterial PEO. Average follow-up of patients was 5.5 years (range, 2 to 11 y). Results: Boys were more commonly affected (11/18). Distal femur was the most common site involved (12/18). Eleven patients had Mycobacterium tuberculosis as the causative organism, 6 were positive for Staphylococcus aureus, and 1 for Brucella. Swelling and limp were predominant in patients with Tubercular PEO, whereas pain was more common in bacterial PEO. Nine of 11 patients with Tubercular PEO had penetration into the joint, whereas none in bacterial PEO. All patients recovered completely without residual movement restriction or growth alteration. On follow-up magnetic resonance imaging, 4 patients with Tubercular PEO had thinning of articular cartilage. Conclusion: High index of suspicion is required for early diagnosis of PEO. It is important to differentiate Tubercular from other bacterial PEO as it has more subtle symptoms and poor prognosis if left untreated. Aggressive surgical treatment followed by antibiotic therapy of appropriate duration is required to avoid complications related to joint destruction. To our knowledge, this is the largest reported series with longest follow-up.

Background:The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV)1-4. The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation.Description:A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position.Alternatives:Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction5. Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article.Rationale:This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique.Expected Outcomes:This technique provided satisfactory clinical outcomes in our previous study6, with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure.Important Tips:The steps need to be followed sequentially as described in order to achieve an anatomical reduction.After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex.This technique may not work in complex fractures with elbow dislocation because of the lack of ligamentous integrity.In the final s...

Background: Shoulder imbalance secondary to residual brachial plexus birth palsy requires release of internal rotation contracture and tendon transfer. Subscapularis is considered as the prime element of internal rotation contracture and various methods have been described for subscapularis lengthening. It includes open subscapularis slide or lengthening and arthroscopic release. We hypothesized that subscapularis can be released through minimally invasive approach from the medial border of scapula and thus avoiding formal open procedures and risk of weakening the internal rotation strength. Methods: Safety zones to avoid injury to important neurovascular structures while performing minimally invasive subscapularis release (MISR) were determined through cadaveric dissection. Between 2014 and 2016, 45 patients underwent MISR. A concomitant conjoined Latissimus Dorsi and Teres Major transfer was performed. Twenty patients with minimum 2-year follow-up were included in this study. Average age of patients was 6.4 years. A 5-point modified Mallet Score, degrees of active and passive rotations and abduction were used as outcome measures. Axial MRI imaging were available to classify the gleno-humeral deformity. Results: Mean improvement in passive external rotation was 80 degrees and in active external rotation was 43 degrees (P <0.001) at 3 months, which was maintained at final follow-up. Average shoulder abduction improved from preoperative—101 degrees to postoperative—142 degrees. Aggregate 5-point Mallet Score improved from 12.8 points (range, 11 to 16) preoperatively to 18.5 points (range, 16 to 21) postoperatively. None of the patients developed external rotation contracture. The results were comparable with other existing techniques of subscapularis release with conjoint tendon transfer. Conclusions: MISR with conjoined tendon transfer is an effective way of treating internal rotation contracture in children with congruent glenohumeral joints. This procedure has shown beneficial outcomes even in patients with noncongruous glenohumeral joints, when performed in children younger than 4 years. Advantages of MISR include less risk to neurovascular structures, minimal soft tissue trauma, directly addressing the medial tight subscapularis fibers, significantly less surgical time and minimum learning curve. Levels of Evidence: Level III—retrospective comparative study.