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The evaluation of the internship in pediatric orthopedics is based on a clinical examination in the form of ECOS, after the internship period involving all surgical specialties. The validation of the clinical examination test does not necessarily mean that the student has achieved his internship objectives and vice versa. This discrepancy between the evaluation test and the field of the internship prompted us to question the need to establish a formative evaluation method during the clinical internship.Our study is a prospective, evaluative, longitudinal study, from October 2019 until September 2020, in the infantile orthopedics and traumatology department of the "Béchir HAMZA" children's hospital in Tunis. We carried out a formative evaluation using the "Patient Management Problem" (PMP), with two different subjects, one on acute hematogenous osteomyelitis, the other on malignant bone tumors, with a Pre-test and a Post-test for each PMP.We had 18 interns, during the period between October 2019 and September 2020, including 13 who had medical training in Tunisian faculties. The score for the acute osteomyelitis pretest was 14.56 on average, the PMP score was 16.33 on average, with one interne scoring zero. The posttest mean was 18.11 [13.75-20], with a statistically significant difference from the pretest. The pre-test for the bone tumors' PMP had an average of 9.7 [3.75-15], that of PMP was 12.6 [0-20]. There was an improvement in post test scores with an average of 16.45. Comparing the two tests we noticed that the scores for the PMP osteomyelitis were higher than the scores for the PMP bone tumors with a significant difference between the two groups (p = 0.04).The results of this pilot project are encouraging for the establishment of a continuous evaluation by the PMP method, intended for interne during the pediatric orthopedic surgery internship. This method allows learning and formative evaluation of learners by evaluating clinical and therapeutic reasoning.

Introduction and importance Navicular bone location of primary subacute hematogenous osteomyelitis uncommon. There are few cases reported in literature. We aim to describe the clinico-radiological features of primary subacute hematogenous osteomyelitis of the navicular bone in a 7-year-old child, to explain our management of this rare disease and demonstrate that medical treatment without surgery is enough. Case presentation A 7-year-old child presented to emergency department. His chief complaint was fever, left limping and foot pain. The positive examination features of were painful palpation of the dorsal side of the foot and a swelling of the homolateral ankle. The erythrocyte sedimentation rate was high. The x-ray revealed a lytic lesion of the left navicular bone. The MRI findings led to the diagnosis of subacute osteomyelitis. Pain relief and normalization of inflammatory markers were obtained after 8 weeks of antibiotic therapy. Complete radiological healing was obtained after 9 months. One year after treatment, the patient was able to practice sports as previously. Clinical discussion Subacute osteomyelitis of the navicular bone in pediatric population is a rare condition. This case shows the importance of early diagnosis thanks to MRI findings and appropriate antibiotic therapy based on the endemic bacteriological profile. Conclusion The navicular bone may develop primary subacute osteomyelitis in immunocompetent child. Early diagnosis is important for prescribing effective conservative treatment., Highlights • Subacute osteomyelitis of the navicular bone is an etiology of lameness in children. • The penumbra sign on MRI is strongly suggestive of the infectious origin of the bone involvement. • Medical treatment without surgery can lead to a cure. • Antibiotic therapy should be sufficiently prolonged for at least 3 months.

Highlights • The treatment of bone defect is fraught with difficulties especially in septic conditions. • Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. • Illizarov fixator is an attractive technique for solving discrepancy of the upper limb., Introduction The management of large bone defect in the upper limb is fraught with difficulties and problems. It’s is a long course treatment which include many components: infection, osseous loosening and shortening. Case presentation We present our experience of an 12-years-old boy with septic non union of the proximal left humerus with length discrepancy of 6 cm treated with Ilizarov fixator(IL) followed by vascularized fibula graft (VFG) with a good clinical result without complications. Discussion The bone loss may be treated with allografts, bone transfer and bone substitute. Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. Conclusion Ilizarov fixator is an attractive and the most used technique for solving the problem of discrepancy and stabilizing in the upper limb.

Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.IV, Case series.

Introduction Septic osteomyelitis is a hematogenous bacterial bone infection. The acute presentation is the most common; the subacute one is less frequent. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. Presentation of case We report a rare case of subacute osteomyelitis associated with Brodie's abscess of the tibial diaphysis in a four-year-old child. The chief complaint was a pain in the left tibia evolving for five weeks. The radiological findings and the unusual location of this pathology suggested a malignant bone tumor. Thanks to imaging assessment and bone biopsy the diagnosis of subacute osteomyelitis associated with Brodie's abscess was made. Therefore, the child had antibiotic therapy and plaster immobilization to avoid pathological fracture. Pain relief and radiological improvement was obtained after 3 months of antibiotic treatment. At a two-year follow-up, the X-ray was normal. Discussion We report an uncommon case of subacute osteomyelitis which evolved to Brodie's abscess with diaphyseal location. The mainstream treatment is surgery combined with antibiotics. However, medical treatment alone can lead to recovery without sequelae. Conclusion Because of the atypical location and presentation of subacute osteomyelitis, the other differential diagnoses, especially malignant bone tumors have to be eliminated. In some cases, treatment may be based on antibiotics therapy alone., Highlights • The MRI findings can mimic a malignant bone tumor. • The importance of the biopsy for the diagnosis. • Antibiotic treatment without surgery is an alternative for the treatment of circumscribed Brodie’s abscess.

Purpose The aim of this case report is to show that late diagnosis of vertebral osteoid osteoma gives rise to structural scoliosis which sometimes requires long-term management. Methods We report a case of an osteoid osteoma in the thoracic spine associated with structural scoliosis. We describe a 14-year-old boy who complained chronic nightly left back pain and scoliosis. Spine’s X-ray was reported thoraco-lumber scoliosis without bone lesion. Results MRI as well as technetium-99 m total body bone scan and a computed tomography scan revealed a bony lesion in the upper left joint of T11 vertebra consistent with the diagnosis of OO. Anatomopathological study of the resection piece confirmed the diagnosis of OO. Surgical excision of the tumor resolved pains, but scoliosis needed an orthopedic treatment for 1 year. Conclusion Through this case, it has been demonstrated that late diagnosed vertebral OO can be the cause of structural scoliosis. Clinical and radiological results indicate that OO resection is an effective and safe method of treatment. Levels of evidence IV.

Tuberculosis is a topical issue in endemic countries. Foot involvement is rare and accounts for 5-10% of all osteoarticular tuberculosis. Pediatric cases of osteoarticular tuberculosis are uncommon especially in well vaccinated children. The clinical presentation is not specific and can be confused with common germ like staphylococcus. Biopsy is mandatory in endemic zone, and if the evolution is not good with antibiotherapy. Debridement can be indicated but must be gentle, because of the risk of navicular necrosis.

Introduction and importance Most of the time, intramuscular hydatid cysts are secondary. The unusual topographies are a source of diagnostic delay and treatment difficulties. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. Case presentation We report the case of a primary hydatid cyst located in the right lumbar paraspinal muscles in a ten-year-old girl, in good health and without a pathological medical history. The patient presented with a discreet right lumbar swelling of firm consistency, painless and without signs of inflammation. Ultrasound and magnetic resonance imaging suggested the diagnosis of an intramuscular paravertebral hydatid cyst. The hydatid serology was positive. The patient had en-bloc resection of the cyst. He was infected with pus. The histopathological examination confirmed the diagnosis of muscular hydatidosis. Medical treatment was started. Three years after the operation, the MRI confirmed that was no recurrence. Clinical discussion Echinococcus is a parasitic cestode that can infect dogs and other pets and farm animals, with humans as incidental hosts. Muscular hydatid localization, secondary to hematogenous dissemination, is rare, even in endemic countries. The combination of medical treatment with surgery ensures the best condition to avoid recurrence. Conclusion In regions where hydatidosis is endemic, a tumor in any part of the body should be considered a hydatid cyst until proven otherwise., Highlights • In endemic areas, any swelling should suggest hydatid cyst. • A negative hydatid serology does not rule out the diagnosis of hydatid cyst. • The hydatid cyst infection can occur through the hematogenous route. • MRI is efficient for the diagnosis of infected hydatid cyst. • The infection can sterilize the hydatid muscle cyst.

We describe a case of osteomyelitis, in a 7-month-old boy, caused by S. pneumoniae involving the pelvic bone with a purulent collection in the adductor muscle. Osteomyelitis diagnosis was suspected using ultrasound and CT scan investigations. This showed a periosteal elevation in the Case Study Ben Marzouk et al.; IJMPCR, 3(3): 68-72, 2015; Article no.IJMPCR.2015.038 69 pelvis and an abscess of the adductor muscle. Culture of the perioperative specimens isolated serotype 19A S. pneumoniae with reduced susceptibility to penicillin and macrolides. The patient was treated successfully with amoxicillin-clavulanate during five weeks, associated with gentamicin during the first week.

Summary Introduction Deep venous thrombosis (DVT) is rare in children. It may complicate acute hematogenous osteomyelitis (AHO). Objective The present study assessed the incidence of DVT in community-acquired AHO, and compared clinical and laboratory characteristics with AHO without DVT. Patients and methods A prospective study included patients treated for community-acquired AHO between April 2007 and December 2009. Results Seventy patients were included: mean age, 7.7 years. Seven developed DVT. All involved Staphylococcus aureus. The isolated Staphylococcus aureus was significantly more often methicillin-resistant than methicillin-susceptible (p = 0.04). C-reactive protein, erythrocyte sedimentation rate, positive blood culture and incidence of pulmonary staphylococcus were significantly higher in patients with DVT. These patients also had significantly more febrile days. One patient with DVT died from severe refractory respiratory failure. Discussion DVT was observed in 10% of cases of community-acquired AHO. DVT was associated with more severe onset, with extensive local disease. Surgery was often needed to drain a subperiosteal abscess. DVT can cause invasive and life-threatening infection through septic emboli, particularly to the lungs. Level of evidence Level III.