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Resume Le syndrome de Protee est une maladie hamartomateuse congenitale rare responsable de deformations orthopediques frequentes. Le resultat et les complications du traitement chirurgical de ces deformations sont mal connus vu la rarete des cas rapportes. Les auteurs rapportent le cas d’une evolution defavorable d’une osteotomie tibiale valgisante proximale chez une patiente de six ans porteuse d’un syndrome de Protee. L’evolution s’est faite vers une necrose profonde etendue de la voie d’abord avec mise a nu de l’os, necessitant une excision chirurgicale, une antibiotherapie ainsi qu’une cicatrisation dirigee. Il y a eu recidive de la deformation orthopedique au recul de 1 an. La possibilite de complication grave et de recidive en cas d’abord chirurgical pour intervention orthopedique chez les patients porteurs de syndrome de Protee doit etre connue. Ces complications doivent etre prises en compte dans le choix de la technique chirurgicale correctrice et peuvent faire preferer les techniques d’epiphysiodese aux osteotomies.

Introduction Proteus syndrome is a rare congenital hamartomatous disease frequently responsible for musculoskeletal deformities. The results and complications of surgical treatment are not well documented owing to the scarcity of reported cases. Case report The authors report a case of poor evolution of valgus proximal tibial osteotomy in a 6-year-old girl with Proteus syndrome. The surgery was complicated by extensive deep wound necrosis exposing the tibial bone, necessitating surgical excision, antibiotherapy and controlled wound healing. At 1 year postoperatively, the deformity recurred. Discussion The possibility of serious wound complications and of recurrence must be kept in mind when operating on a limb deformity in patients with Proteus syndrome. Potential complications should be taken into account in selecting the surgical correction technique: epiphysiodesis may be preferable to osteotomy.

Resume Nous rapportons une serie de 26 cas d’osteomyelite du calcaneum, afin d’etudier les particularites cliniques et paracliniques de cette localisation rare. Le tableau clinique n’etait pas specifique. La temperature n’etait superieure a 38,5 °C que dans 45 % des cas. La symptomatologie etait celle d’un syndrome douloureux et febrile de l’arriere-pied avec une impotence fonctionnelle du membre. La douleur etait a distance du calcaneum, ce qui a fait errer le diagnostic dans six cas. Le syndrome inflammatoire biologique n’etait pas constant. Une leucocytose superieure a 10 000 par millilitre n’a ete notee que dans 61 % des cas. Le diagnostic de l’osteomyelite du calcaneum a ete retenu sur la radiographie standard, en montrant une geode au niveau de calcaneum dans 12 cas, sur l’echographie, realisee chez 19 malades et qui a montre six decollements sous-periostes au niveau de calcaneum, trois collections au niveau de l’arriere-pied et quatre epaississements des parties molles. La scintigraphie osseuse, realisee dans un cas, a montre une hyperfixation en regard du calcaneum. L’IRM, realisee chez un patient, a pu mettre en evidence une anomalie de signal au niveau de calcaneum sous forme d’un hypersignal T2 et hyposignal T1, avec la presence d’un abces sous-perioste. L’enquete bacteriologique etait positive dans 53 % des cas. Le traitement etait medical dans tous les cas, 23 enfants ont du subir un acte chirurgical. Nos resultats ont ete etudies avec un recul moyen de deux ans avec des extremes de un an a sept ans. Dix-neuf malades (73 %) n’ont garde aucune sequelle. Sept malades (27 %) ont presente des mauvais resultats avec limitation importante de la mobilite au niveau de l’arriere-pied et une ankylose de la cheville. On a note sept passages a la chronicite avec fistules, dont une reste productive au dernier recul. Les mauvais resultats ont ete observes chez des patients traites tardivement avec un delai moyen de consultation de 17 jours. Six mauvais resultats sur sept associent des arthrites a l’atteinte du calcaneum (atteinte de la sous-talienne et la tibiotarsienene dans deux cas et atteinte de la sous-talienne dans quatre cas).

Resume Nous rapportons une serie de 28 cas d’osteomyelite du col du femur afin de mettre en evidence les particularites cliniques et paracliniques de cette localisation. Le tableau clinique non specifique etait fait d’un syndrome douloureux de la hanche dans un contexte febrile. Le diagnostic de l’osteomyelite du col du femur a ete realise en se basant, sur l’imagerie (IRM et scintigraphie) dans trois cas avec une preuve bacteriologique dans deux cas, sur les constatations operatoires qui ont confirme l’atteinte du col dans 19 cas et sur les modifications de l’aspect radiologique du col dans six cas. Le traitement a ete medical dans tous les cas, 25 malades ont du subir un acte chirurgical. On a note cinq complications thromboemboliques et cinq cas d’evolution vers une pandiaphysite femorale. Nos resultats ont ete analyses avec un recul moyen de trois ans et demi. Sur le plan fonctionnel, la mobilite de la hanche etait complete dans 78 % des cas. On a observe quatre cas de raideur de la hanche et deux cas d’ankylose. Sur le plan anatomique, on a note deux cas de necrose cephalique partielle et deux cas de necrose totale de la tete et du col. L’analyse de nos resultats a montre que le pronostic de l’osteomyelite du col du femur est fonction du delai de prise en charge. Les malades traites tardivement presentent des mauvais resultats. L’evolution vers une pandiaphysite est un facteur pejoratif.

Resume Objectif Le but de ce travail est de rapporter les elements semiologiques IRM permettant d’orienter vers le diagnostic de crise vaso-occlusive en cas de douleur osseuse aigue febrile chez un enfant drepanocytaire. Materiels et methodes Une exploration par IRM (sequences spin-echo en ponderation T1 et T2 et en ponderation T1 avec saturation de graisse sans et avec injection de Gadolinium) a ete pratiquee chez 10 enfants drepanocytaires, explores pour douleurs osseuses febriles. Le diagnostic de crise vaso-occlusive a ete retenu devant une reponse rapide au traitement symptomatique et une bacteriologie negative. Resultats L’IRM a ete pathologique dans tous les cas. L’atteinte multifocale a ete notee dans 2 cas. Les anomalies du signal medullaire ont ete constantes. Dans 10 cas, l’atteinte a ete metaphyso-diaphysaire a type d’hypersignal T1 et T2. La prise de contraste est constante et heterogene avec un aspect en tache d’encre. Les anomalies periostees ont ete notees dans 8 cas, elles sont precoces, d’aspect inflammatoire ou stratifie. Un amincissement de la corticale a ete note dans 1 cas. L’atteinte des parties molles a ete observee dans 5 cas, de type inflammatoire dans 4 cas. Conclusion L’atteinte synchrone de plusieurs os, les anomalies du signal medullaire en rapport avec des produits de degradation de l’hemoglobine, la prise de contraste heterogene, l’anomalie precoce du perioste et l’atteinte discrete des parties molles, orientent vers le diagnostic de crise vaso-occlusive.

Resume But. – Le but de ce travail etait de rappeler qu’il existe de veritables paralysies du plexus brachial d’origine infectieuse osteoarticulaire. Observations. – Il s’agissait de trois nourrissons âges de moins de trois mois et d’un nouveau-ne de six jours qui ont presente une paralysie du plexus brachial dont la cause etait une osteoarthrite de l’epaule. Le diagnostic de l’osteoarthrite a ete fait sur des arguments cliniques, biologiques, d’imagerie et evolutifs. Dans un cas, le germe causal, un Enterobacter, a pu etre isole. Le diagnostic de la paralysie etait essentiellement clinique. Dans un cas, une electromyographie a mis en evidence la souffrance du plexus brachial. Le traitement a associe une antibiotherapie et des ponctions iteratives. La recuperation etait complete dans les quatre cas dans un delai de moins d’un mois. Commentaires. – L’infection osteoarticulaire de l’epaule est reconnue actuellement comme une cause de paralysie du plexus brachial. Une thrombophlebite septique du vaisseau nourricier des nerfs ou une compression extrinseque sont incriminees dans la genese de la paralysie. Le diagnostic et le traitement de l’infection doivent etre precoces.

Introduction : Pott's disease is the most frequent localisation of osteoarticular tuberculosis. The authors report a case of cervical Pott's disease with lateropharyngeal abscess. Observation : Our patient is a 44 years old pilot; he presented since 6 months cervicalgy, dysphagia and weighting loss. Clinical findings showed a swelling of posterior and lateral oropharyngeal wall extending to hypopharynx. A palsy of the XI th nerve and an abolition of the bicipital reflex were also noticed. CT scan showed a lateropharyngeal collection extending from C4 to D1. It was also noticed a subtotal destruction of C6. However, there were no medullar lesions in the cervical spine MRI. Tuberculosis was confirmed thanks to histological analysis of caseum taken during cervical biopy. The patient was operated using anterior approach. He had surgical removal of C6 which was replaced by iliac prothesis. Medical treatment was based on antituberculosis drugs used during 12 months. After three years of follow up, the out come was favourable with no recurrence and satisfying consolidation. For aeronautic considerations, the patient was declared unable for flying mission. Conclusion : Tuberculosis constitutes a problematic infectious disease in Tunisia which may have serious consequences on publish health. We insist on preventing measurements because there are neither specific clinical findings nor radiological characterising features. Keywords : Tuberculosis, Pott's disease, lateropharyngeal abscess

Acute osteomyelitis of the rim of the obturator foramen is rarely reported. The clinical presentation is atypical, making diagnosis a difficult task. We report a series of seven cases of osteomyelitis of the obturator rim which illustrate the different features of this localization.The series included seven boys with osteomyelitis involving the obturator foramen. We reviewed the clinical history, the diagnostic approach and management. Complications and anatomic outcome were noted at mean three years follow-up (range one to 10 years).Mean age was 9.5 years (five to 12 years). Bilateral involvement was noted in one boy. Mean time from symptom onset to consultation was five days and mean time from consultation to hospitalization was eight days. No specific clinical presentation could be identified. Fever was not a constant feature. Mean body temperature was 38.6 degrees C and was not greater than 38.5 degrees C in four children. Symptoms were limited to hip pain in five cases and abdominopelvic pain was noted in two. Physical examination failed to trigger exquisite ischial or pubic pain in two patients. The osteomyelitis involved the ischiopubic ramus in four cases, the ischium in two with one bilateral case, and the pubis in one. Certain diagnosis was established as follows: MRI findings plus isolation of the pathogenic agent (n=4) ; the plain x-ray showed a defect in the ischiopubic ramus, MRI showed signs favoring osteomyelitis of the ischiopubic ramus and surgery evacuated a purulent collection (n=1) ; strong uptake of the obturator rim on scintigraphy (n=2). Medical treatment was given in all cases and surgery was performed in six patients. Outcome was noted at three years follow-up, range one to 10 years. All patients recovered normal function. There were no complications.Hematogenous osteomyelitis of the pelvis is exceptional (2-11 % of cases of osteomyelitis). Localization in the obturator rim is rare. We discuss the specific diagnostic and therapeutic features of this localization. Despite the controversy concerning the treatment of pelvic osteomyelitis and in particular cases involving the obturator rim, prognosis is generally good. No complications have been described in the literature specifically associated with osteomyelitis of the obturator rim.

Osteomyelitis of the neck of the femur is uncommon, often with a misleading clinical presentation. We report a series of 28 cases of osteomyelitis of the femoral neck to illustrate the particular clinical and imaging findings related to this localization.This was a series of 28 children treated in our unit from 1990 through 2004: 17 boys and 11 girls, mean age eight years (range one month to 14 years). We analyzed the data in this series using a standard checklist, which noted the diagnostic and therapeutic measures. Results were analyzed by studying the complications, anatomic and functional outcome at mean follow-up of 3.5 years.Time from symptom onset to consultation was five days on average with a delay of 4.5 days from consultation to hospitalization. Intense pain was noted for eight patients (28%) and total functional incapacity of the limb was noted for 15 (53%). Hip stiffness was observed in 11 patients (39%). The diagnosis of osteomyelitis of the femoral neck was established on the basis of imaging (MRI or scintigraphy) in three patients with bacteriological proof in two, of operative findings which confirmed the neck localization in 19, and on changes in the X-ray image of the neck in six. A positive bacteriology was noted in 71%. The germ was isolated from blood cultures and local samples obtained by arthrotomy in five patients (same germ), only in blood cultures for four, and only in local samples in 11. Met-S Staphylococcus aureus was isolated in 18 patients, Met-R S. aureus in one and a Streptococcus in one. All patients were given medical treatment and 25 underwent surgery. There were five thromboembolic complications and five patients who developed femoral pandiaphysitis. Results were analyzed at mean 3.5 years (range four months to 14 years). Complete hip motion was recovered in 78%. There were four cases of hip stiffness and two cases of ankylosis. Partial cephalic necrosis was noted in two hips and total necrosis of the head and neck in two.Little data is available in the literature on isolated osteomyelitis of the femoral neck. Based on the pathogenic mechanisms known for osteomyelitis, an isolated localization in the neck of the femur, with no other site in the hip joint, is quite possible in an early stage of infection. We discuss the specific clinical and imaging features of this localization. Analysis of our findings show that the prognosis of femoral neck osteomyelitis is directly related to time to management. Outcome is poorer when treatment is started late. Prognosis is poor if pandiaphysitis develops.

Reduction of developmental dislocation of the hip is difficult to achieve in children after walking age and particularly in older children. In fact, at this age the important retraction of the muscles around the hip associated with a marked acetabular dysplasia and elongation of the joint capsule explain the difficulty and instability of reduction and the frequency of complications. In this study we reviewed retrospectively the clinical and radiological results of 26 developmental dislocations of the hip treated by open reduction, pelvic osteotomy and femoral shortening in 21 children aged more than 5 years. Age at surgery ranged from 5 to 11 years (mean 7.5 years) with a follow-up of 1 to 8 years (mean 2 years 7 months). According to the clinical classification of MC Kay, 17 hips had a good result while 9 hips had a fair or poor result. According to the Severin classification system 18 hips had an excellent and good radiological result. Ten hips developed an avascular necrosis of the femoral head following the reduction.

The aim of this study was to report the MRI findings that can suggest a vaso-occlusive crisis in cases of febrile osseous pain in children suffering from sickle cell disease.MRI (T1 and T2 weighted sequences and T1 weighted sequence with fat saturation before and after gadolinium injection) was performed in 10 children with sickle cell disease, presenting with febrile osseous pain. The diagnosis of vaso-occlusive crisis was made after fast improvement due to symptomatic treatment and negative bacteriological result.MRI was abnormal in all cases. A multifocal localisation was found in 2 cases. Bone marrow abnormalities were constant. In 10 cases, high T1 and T2 signal and metaphyso-diaphysial lesions were noted. Heterogeneous medullar enhancement with "ink stain" feature was constant. Early periosteal abnormalities were noted in 8 cases with inflammatory or stratified features. Cortical thinning was found in 1 case. Soft tissue abnormalities were observed in 5 cases with inflammatory features in 4.Multifocal synchronous localisation, medullar abnormalities resulting from hemoglobin degradation, heterogeneous enhancement, early periosteal abnormalities and associated soft tissues swelling are MRI findings suggesting acute vaso-occlusive disease.

To assess the value of MRI for early diagnosis of osteomyelitis in children presenting with sepsis and acute onset of musculoskeletal pain.MRI including fat suppressed T2W, and fat suppressed pre- and postcontrast T1W sequences was performed within 48 hours of admission in 26 children with clinical (fever and acute musculoskeletal pain) and biological (elevated WBC count and ESR in all cases, and elevated CRP in 12 patients) suspicion of acute osteomyelitis. None of the patients had sickle cell disease.MRI was normal in 7 children (26%). Bone marrow signal abnormality was noted in 19 cases (74%) consistent with acute osteomyelitis in 18 cases and metastatic neuroblastoma in 1 case.MRI is useful for evaluation of children presenting with sepsis and acute musculoskeletal pain, early diagnosis of osteomyelitis and to prevent unnecessary hospital admission and work-up.

Osteo-articular tuberculosis is rare in infants. The MRI findings reported for adolescents and young adults mainly relate to spinal involvement. Two cases of osteo-articular tuberculosis of infants located at the knee are presented. Vaccination has been correctly done. Skin test and chest radiography were normal. Evolution was insidious for one case. Osseous, medullary, cartilaginous and soft tissue abnormalities revealed by MRI were suspicious for tuberculosis. Diagnosis was confirmed at histology for both cases and bacteriology for one case. The aim of this study is to report the MRI features of osteo-articular tuberculosis in pediatric patients.

The authors report 2 cases of concomitant scaphoid and distal radial fractures, a rare combination of lesions in children. The first case was in a 13-year-old boy who presented a transverse midscaphoid fracture associated with a Salter type II distal radial fracture. The second concerned a 10-year-old boy who presented a bilateral wrist injury. On the left side, a distal forearm fracture with anterior displacement was associated with a transverse midscaphoid fracture. On the right side, there was only a distal forearm fracture. Scaphoid fracture associated with distal radial fracture seems to have been more frequently reported in the literature during the last decade, probably because it is more frequently recognised. In fact, children with distal forearm injury should be well examined both clinically and radiologically in order to search for an associated scaphoid fracture. Reduction of the radius fracture should be done carefully to avoid possible displacement of the scaphoid fracture.

Brachial plexus palsy (BPP) may occur after septic osteoarthritis of the shoulder. BPP is a rare, well recognized complication. The pathophysiology is thought to be either ischemic nerve damage secondary to occlusion of vasa nervorum or extrinsic compression. Early diagnosis and treatment of the infection are needed.We report the cases of three infants aged less than three months and one six-day-old newborn infant who presented with an authentic BPP due to an osteoarthritis of the shoulder. The diagnosis of osteoarthritis relied on clinical, biological and radiological signs. In one case, the causal germ (Enterobacter) was isolated. The diagnosis of the palsy was based on clinical signs. EMG performed on one patient, showed signs of abnormal motor pattern. Following intravenous antibiotics and percutaneous drainage, all infants completely recovered.

Introduction L’osteomyelite aigue de l’ischion est une entite rare. Le tableau clinique est souvent atypique rendant le diagnostic difficile. Nous rapportons une serie de sept cas d’osteomyelites de l’ischion afin d’etudier les particularites cliniques et para-cliniques de cette localisation osteomyelitique. Materiel et Methodes Il s’agissait de sept garcons ayant un âge moyen de neuf ans et demi avec des extremes de cinq ans a 12 ans. Dans un cas, l’atteinte etait bilaterale. On a note un retard de prise en charge avec un delai moyen symptomes-consultation de cinq jours et un delai moyen consultation-hospitalisation de huit jours. Le tableau clinique n’etait pas specifique. Le syndrome febrile n’etait pas present dans tous les cas. On a note une fievre a 38,6C en moyenne et la temperature n’etait superieure a 38,5C que dans quatre cas. La symptomatologie clinique se resumait a un syndrome douloureux de la hanche dans cinq cas. La douleur etait abdomino-pelvienne dans deux cas. L’examen physique initial n’a note la douleur exquise ischiatique que dans deux cas. — Le diagnostic de l’osteomyelite de l’ischion a ete retenu comme suit ; — dans 4 cas : en se basant sur le resultat d’IRM et en isolant le germe pathogene ; — dans 1 cas : en se basant sur la radiographie standard initiale qui a montre une geode au niveau de l’ischion, l’IRM qui a montre des signes en faveur de l’osteomyelite de l’ischion et la chirurgie qui a permis d’evacuer une collection purulente ; — dans 2 cas : en se basant sur le resultat de la scintigraphie qui a montre une hyperfixation au niveau de la branche ischio-pubienne. Le traitement etait medical dans un cas et medico-chirurgical dans six cas. Resultats Nos resultats ont ete juges avec un recul moyen de trois ans avec des extremes de un a dix ans : Tous les malades ont recupere une fonction normale. Aucune complication n’a ete observee. Discussion Les osteomyelites hematogenes pelviennes sont rares (2 a 11 % des osteomyelites). La localisation au niveau de l’ischion est exceptionnelle. Les auteurs discutent les particularites, cliniques, para-cliniques et therapeutiques de cette localisation osteomyelitique. Conclusion Devant une boiterie douloureuse et febrile chez un enfant, la palpation des reperes osseux au niveau du bassin au cours de l’examen physique, est capitale afin de detecter une eventuelle osteomyelite pelvienne. L’IRM est d’un grand d’apport pour le diagnostic precoce de l’osteomyelite de l’ischion.