Vaikų chirurgijos klinika (K280000)

Introduction Paediatric tibial fractures aren’t uncommon and usually heal uneventfully if treated properly and followed up regularly. However, delayed postoperative care or neglected wound supervision may lead to infectious complications, including osteomyelitis. This case emphasizes that a successful healing process relies on effective family education and strict adherence to the postoperative care plan. Case Presentation A 12-year-old boy sustained a distal tibial fracture following a fall. The fracture required a closed reduction and Kirschner wire fixation, with the wires left external to the skin. The limb was immobilised in a plaster splint and the patient’s parents were given instructions for regular outpatient review. Despite that, the family failed to return for a consultation for nearly 4 months. The patient presented again after swelling, redness and discharge were noted around the pin sites. X-ray, CT and MRI imaging confirmed a diagnosis of osteomyelitis of the distal tibial metaphysis. Surgical debridement was performed and long-term antibiotic therapy initiated. The infection was successfully controlled and the patient regained good limb function. Discussion Delayed or absent postoperative monitoring can transform an otherwise straightforward fracture into a serious infectious complication, potentially leading to growth disturbances or deformity.[1] Given this risk, it is important to anticipate such scenarios and implement strategies to optimize patient outcomes. Variety of socioeconomic factors, including socioeconomic deprivation, help to determine an adolescent patient’s risk of poor care compliance after sustaining a fracture. Awareness of these factors allows clinicians to identify patients who may benefit from extra time spent emphasizing the importance of timely followup care.[2] Conclusions This case highlights that even technically correct surgery may lead to severe complications if postoperative care is neglected. Effective communication, family education, and close followup are key to preventing osteomyelitis in paediatric fracture management. Early recognition and timely intervention are essential to ensure full recovery and avoid long-term disability.

Introduction Radial head fractures account for 4.5–21% of paediatric elbow injuries. They most commonly occur after a fall onto an outstretched hand, transmitting axial force through the radius. Early diagnosis is critical to prevent complications. Treatment depends on displacement and stability, with both conservative and surgical approaches often achieving good outcomes. Case Presentation Eight-year-old gymnastics injured her elbow after a fall on an outstretched arm. She presented to the hospital immediately after the injury, but the initial radiographs missed the radial head fracture, which was diagnosed only three to four weeks later. Repeat imaging revealed a fully displaced and laterally migrated radial head with early callus formation, indicating a late stage of healing. Due to the displacement, surgical intervention with open reduction and internal fixation was recommended. However, the parents declined surgery, over concerns about complications, so the patient was managed conservatively with close follow-up. Despite persistent lateral displacement on radiographs, she is pain-free with full elbow motion and normal forearm rotation and has returned to sports. Her short-term outcome is excellent, though the long-term prognosis remains uncertain. Discussion Developing ossification centres can make early fractures easy to miss, and delayed diagnosis may lead to displacement, malunion or early ossification, complicating later treatment. Operative treatment is recommended for angulation > 30° or translation > 3 mm, but studies show good function may still occur with non-anatomical union if joint mobility is preserved. This case demonstrates the unpredictable course of late-diagnosed radial head fractures. The patient is currently asymptomatic with full function, but future risks include growth deviation, elbow valgus, or limited forearm rotation. Conclusions This case highlights the importance of accurate radiographic assessment in paediatric elbow trauma. Delayed-diagnosed fractures may function well short-term without surgery, but longterm outcomes are uncertain. Therefore, regular follow-up throughout growth is essential to detect deformities or functional issues and ensure optimal outcomes.

Introduction Developmental dysplasia of the hip (DDH) is a common pediatric orthopedic condition. Early diagnosis allows effective conservative treatment, whereas delayed diagnosis may result in fixed dislocation, acetabular dysplasia, and the need for surgical reconstruction. This case report presents successful operative management with open reduction combined with Salter pelvic osteotomy after failed conservative treatment. Case Presentation A 2.5-year-old child was diagnosed with unilateral developmental dysplasia of the hip with dislocation at 14 months. Clinical examination revealed pelvic asymmetry, mild limb length discrepancy and limited abduction. MRI confirmed unilateral hip dislocation and acetabular dysplasia. Conservative treatment with bracing, closed reduction and coxitis cast was unsuccessful. Open reduction with Salter osteotomy using an iliac graft was performed, followed by pelvic cast immobilization. Post-operative imaging confirmed positive acetabular roof positioning and consolidation. No complications occurred during follow-up. Discussion DDH outcomes largely depend on age at diagnosis. Conservative treatment is effective in infants, but less successful in older children. In this case, delayed diagnosis resulted in closed reduction failure, consistent with evidence showing higher complication and reoperation rates after closed reduction in children over 12 months (1,2). Open reduction enables stable concentric reduction; when combined specifically with Salter pelvic osteotomy, it improves acetabular coverage and provides favorable long-term clinical and radiographic outcomes. Among several available pelvic osteotomies for DDH, the Salter technique is well established for children in this age group (3). Redislocation after open reduction remains a serious risk due to the potential development of avascular necrosis (4). In this case, open reduction with Salter osteotomy achieved stable alignment without complications. Conclusions Delayed diagnosis reduces the effectiveness of conservative treatment in DDH. When closed reduction fails or DDH is diagnosed after infancy, open reduction combined with Salter pelvic osteotomy represents a single, comprehensive surgical strategy. This approach provides stable reduction and promotes improved acetabular development.

Introduction Traumatic diaphragmatic hernia (TDH) is a rare pediatric injury (<1% of trauma cases). Leftsided defects are more common but may be overlooked, particularly when initial imaging is negative. Delayed diagnosis increases the risk of visceral herniation, respiratory compromise, and life-threatening complications [1]. Case Presentation An 11-year-old girl presented with severe respiratory distress, abdominal pain, and persistent vomiting. She was initially treated for suspected pneumonia; however, chest X-ray revealed herniation of the stomach into the right thoracic cavity. Medical history revealed severe polytrauma with predominant head injury following a motor vehicle accident two years earlier, with an initially unremarkable thoracic CT scan. In the preceding months, the patient experienced recurrent self-limiting episodes of vomiting and abdominal pain. The patient was transferred to a tertiary center where emergency laparotomy revealed herniation of a markedly distended stomach containing approximately 4 liters of gastric contents, along with the left hepatic lobe, through a 5-cm diaphragmatic defect. Primary diaphragmatic repair was performed. Postoperatively, the patient developed right lung consolidation, suspected to be aspiration pneumonia, requiring high-flow oxygen therapy. Broad-spectrum antibiotics were initiated. The patient was discharged in good condition 9 days postoperatively and remained asymptomatic at follow-up. Discussion Traumatic diaphragmatic rupture in children is uncommon and often clinically occult, particularly in polytrauma patients where associated injuries dominate initial management. Respiratory symptoms are frequently nonspecific, and normal breath sounds or oxygen saturation do not exclude diaphragmatic injury [2]. Small tears may remain undetected on initial imaging and enlarge over time, allowing delayed herniation of abdominal viscera months or years after trauma. From a pediatric surgical standpoint, timely recognition is critical, as leftsided defects carry a high risk of gastric or intestinal incarceration, necrosis, and perforation [2,3]. Once diagnosed, surgical repair should not be delayed to prevent life-threatening complications [4]. Conclusions In pediatric patients with respiratory symptoms and a history of high-energy blunt trauma, TDH should be considered to avoid delayed diagnosis and prevent life-threatening complications.

Surgical services were poorly prepared for the COVID-19 pandemic, leading to widescale disruption to elective activity. This study aimed to identify actionable priorities to strengthen pandemic preparedness of surgical and hospital systems.

Aim of the study. To assess the experience and challenges associated with diagnosing peritoneal tuberculosis in children. Methods. A literature review was conducted using the PubMed, Web of Science and Cochrane databases, including reported cases of paediatric peritoneal tuberculosis published between 2007 and 2022. Results. The search identified 219 potentially relevant articles; 12 met the inclusion criteria, comprising 37 patients. The most common symptoms were abdominal pain (67.6%), abdominal distension (67.6%) and fever (64.9%). The most frequent ultrasound findings were free fluid in the pelvic cavity (86.5%) and enlarged mesenteric lymph nodes (56.8%). Most culture samples for Mycobacterium tuberculosis were negative. Surgical intervention was performed in 32 cases (86.5%). Histological examination revealed granulomas in all evaluated biopsy samples. Conclusions. The clinical presentation, laboratory findings, and radiological findings of peritoneal tuberculosis are non-specific. This literature review indicates that peritoneal tuberculosis is most often diagnosed following surgery. An algorithm of less invasive procedures and tests is suggested before considering surgical intervention.

Įvadas. Chirurginės žaizdos infekcijos (SSI) yra viena pagrindinių pooperacinių komplikacijų priežasčių, paveikiančių iki 11 % pacientų visame pasaulyje. Jos atsiranda dėl mikrobinio žaizdų užteršimo, kurį lemia paciento sveikatos būklė, chirurginė technika ir sveikatos priežiūros sąlygos. Tyrimo tikslas. Atlikti išsamią pooperacinių infekcijų apžvalgą, vertinant naujausias žinias apie epidemiologiją, rizikos veiksnius, patogenezę, diagnostikos metodus, gydymo galimybes ir prevencijos strategijas. Medžiaga ir metodai. Išsamiai išanalizuota mokslinė literatūra, pasitelkus PubMed duomenų bazę. Į analizę įtraukti tik anglų kalba publikuoti tyrimai, daugiau nei 70% literatūros šaltinių paskelbti 2015–2025 m. Atrinkti tyrimai buvo vertinami pagal jų svarbą epidemiologijos, patogenezės, rizikos veiksnių, diagnostikos ir gydymo sričiai. Rezultatai. Ilgesnės operacijos, prasta antiseptika, nutukimas, nekontroliuojamas cukraus kiekis kraujyje didina SSI riziką. Didžiausi rodikliai yra mažų ir vidutinių pajamų šalyse. Prevencinės strategijos, tokios kaip laiku skiriami antibiotikai, antiseptikos protokolai ir neigiamo slėgio žaizdų terapija, padeda sumažinti sergamumą, nors piktnaudžiavimas antibiotikais ir atsparūs organizmai tebėra didelės problemos. Išvados. Nepaisant pažangos prevencijos srityje, su sveikatos priežiūra susijusios infekcijos tebėra didelė našta. Norint jų sumažinti, reikia griežtos infekcijų kontrolės, geresnių diagnostikos priemonių, racionalaus antibiotikų vartojimo. Ateityje daugiausia dėmesio turėtų būti skiriama į bioplėvelę nukreiptiems gydymo būdams, rizikos prognozavimo modeliams, minimaliai invazinės chirurgijos plėtrai, siekiant pagerinti rezultatus visame pasaulyje.

Temos aktualumas A lateral ankle sprain (LAS) is one of the most common injury, which occurs in children. Despite large number of studies, diversity of treatment strategies persists. Over 20 years acronym PRICE (protection, rest, ice, compression, elevation) and anti-inflammatory drugs (NSAIDs) is first option, despite its lack of high quality evidence. Lately acronym PEACE and LOVE (protection, elevation, avoid anti-inflammatory drugs and icing, compression, education, load, optimism, vascularisation, exercise) was announced, which involves immediate care and rehabilitation of soft tissue damage. It is thought that phases of inflammation help tissue to heal and NSAIDs combined with icing interferes it, so new strategy excludes this combination. Darbo tikslas (-ai) To compare PRICE vs PEACE and LOVE for LAS treatment, to evaluate injury severity outcomes and to verify the need of plaster cast immobilization in adolescents. Tyrimo metodai A prospective randomised study of 65 (37 male, 28 female) patients from 12 to 17 years old who admitted LUHS Paediatric emergency department (ED) in year 2022- 2024 after LAS was executed. Inclusion criteria were first time LAS, acute period of 1 to 4 days after injury, exclusion of chronic pain and any fracture, except avulsion. Depending on symptoms immobilization by plaster cast was applied for 30 patients (46,2%) in the ED. At first visit to the policlinics cast was removed for all of them, lace-up splint was prescribed to all 65 patients and they were randomly allocated to two age and gender homogenous groups: classic (A) PRICE (n = 32, male 62,5%, female 37,5%) or new (B) PEACE and LOVE (n = 33, male 51,5%, female 48,5%) treatment method. Patient diagnose was confirmed by x rays and ultrasound system MyLab 9 eXP 20071, Esaote S.p.A., CE 0123. Ankle function was tested by Biodex isokinetic dynamometer to compare range of motion (ROM) and peak torque to body weight (PEAK TQ/BW) of inversion (IN) and eversion (EV), Y balance test composite scores (YBT CS) were counted to evaluate proprioception between involved (I) and uninvolved (U) legs 1 to 2, 5 to 7 and 12 to 15 weeks after injury comparing two methods. Depending on radiologic findings patients were divided into two groups: I – diagnosed with sprains (grade I) or partial tears (grade II) of lateral ankle ligaments; II – diagnosed with complete tears (grade III) and/or avulsions of lateral malleolus. Data analysis was performed by IBM SPSS 22 software. Two independent samples were compared by Mann-Whitney U test, three measurements in each group were compared by Friedman test. Rezultatai Mean patient age in group was A 14,31 (SD 1,67), in group B 14,64 (SD 1,64). Depending on injury severity 30 patients (46.2%) formed group I and 35 patients (53.8%) group II. There was a significant difference measuring YBT CS deficiencies between U and I legs in group I and II after third testing: YBT-3 CS group I -0,47% vs group II 1,43% (U=353, p=0,02). Only first Biodex testing showed higher deficit of IN for I leg: 1 PEAK TQ/BW IN group I 27,43% vs group II 37,77% (U=358, p=0,028) but later testings showed no significant difference depending on injury severity. Group II showed significantly higher ROM deficit at second and third testing: 2 ROM group I 27,83 ° vs 37,43 ° (U=370, p=0,04), 3 ROM group I 26,53 ° vs 38,54 ° (U=331, p=0,011). Immobilization by plaster cast in the ED was applied to total of 30 (46,15%) patients: 12 (40,0%) group I and 18 (51,4%) group II patients (p=0,357). Application of plaster cast had no better outcomes over 3 testings in IN, EV or ROM: : 3 PEAK TQ/BW IN cast group 31,62% vs no cast group 34,19% (U=483,5, p=0,585); 3 PEAK TQ/BW EV cast group 29,8% vs no cast group 35,74% (U=429, p=0,206); 3 ROM cast group 33,40 ° vs no cast group 32,66 ° (U=513, p=0,875). Two different treatment strategies were compared by Friedman test, pairwise comparisons were performed and B treatment method showed significant better results in YBT CS, PEAK TQ/BW IN and ROM deficit scores: group A YBT CS-1 2,28% and YBT CS-3 1,7% vs group B YBT CS-1 2,42% and YBT CS-3 1,61% (p=0,003); group A 1 PEAK TQ/BW IN 2,09 and 3 PEAK TQ/BW IN 1,84 vs group B 1 PEAK TQ/BW IN 2,27 and 3 PEAK TQ/BW IN 1,68 (p=0,049); group A 1 ROM 2,59 ° and 3 ROM 1,45 ° vs group B 1 ROM 2,64 ° and 3 ROM 1,47 ° (p<0,001). Išvados, rekomendacijos Higher grade of lateral ankle ligaments tear has no significant impact on ankle proprioception outcomes, but has impairement of ROM and early post injury inversion force. Immobilization by plaster cast is used too often even for minor injuries because it has no better outcomes for LAS treatment, it should be used as short as possible and only for pain control. PEACE and LOVE treatment method showed better results than PRICE in YBT CS, ROM and inversion force.

Temos aktualumas Stipinkaulio galvos ir kaklo lūžiai vaikams sudaro apie 10-15% alkūnės srities lūžių. Dažniausiai įvyksta vaikams nuo 7 iki 12 metų, krintant ant ištiestos rankos. Lūžiai dažnai susiję su didele komplikacijų rizika, neretai įvyksta kartu su dilbio kaulų išnirimu, žastikaulio medialinio antrkumplio ar alkūninės ataugos lūžiu. Dislokuotiems lūžiams reikalingas operacinis gydymas, tačiau optimalaus operacinio gydymo metodo dėl šioje zonoje esančios augimo linijos nėra. Darbo tikslas (-ai) Parinkti tinkamą gydymo metodą pacientams, patyrusiems stipinkaulio galvos lūžį. Tyrimo metodai

1. 7 m. mergaitė nukrito nuo suoliuko ant kairės ištiestos rankos ir patyrė kairės alkūnės traumą, atvyko į vaikų SPS, jai buvo atlikta dviejų krypčių alkūnės rentgenograma, diagnozuotas stipinkaulio galvos lūžis su didele dislokacija, todėl buvo stacionarizuota operaciniam gydymui – atlikta atvira repozicija ir vidinė fiksacija, panaudojant 2,0mm diametro elastinę vinį, žiedinis raištis susiūtas. Pritaikytas šarnyrinis įtvaras 5 sav. laikotarpiui – 3 sav. alkūnė fiksuota, likusias 2 sav. – palaipsniui didinta fleksija/ekstenzija, ribojant dilbio rotaciją. Pacientei paskirta 20-ies dienų stacionarinė reabilitacija, po jos alkūnės funkcija buvo patenkinama, neskaudėjo, judesių amplitudė gera. 2 mėn. po operacijos pacientė grįžo į mokyklą, 3 mėn. po operacijos patyrė nedidelę traumą - krito ant kairės alkūnės, tačiau nebuvo hematomos, patinimo ar stipraus skausmo, todėl į gydymo įstaigą nesikreipė. Po kelių dienų pastebėjo ribotą judesio amplitudę, todėl atvyko SPS, atlikus rentgenogramą, diagnozuota implanto migracija, todėl stacionarizuota į VOTS skubiai implanto eliminacijai. Implantas eliminuotas, lūžio stabilumas įvertintas operacinėje C lanko kontrolėje. Nors pilno sugijimo radiologiškai dar nebuvo, tačiau fragmentas stabilus. Nuspręsta pacientę stebėti kas 6 mėn. 2 metai po pirmos operacijos pacientė pradėjo jausti skausmą alkūnėje, alkūnės srityje pastebėta deformacija, atsirado judesių ribotumas. KT ir rentgenogramose – hiperosifikuota stipinkaulio galva, subchondrinės cistos, sklerozė, aseptinės nekrozės požymiai.
2. 7 m. berniukas, nukrito nuo batuto ant kairės rankos. Dėl kairės alkūnės skausmo, tinimo, deformacijos ir negalimų judesių atvyko į vaikų SPS. Atlikta dviejų krypčių rentgenograma, nustatyta stipinkaulio kaklo lūžis su visiška stipinkaulio galvos dislokacija, stacionarizuotas operaciniam gydymui. Operacijos metu atlikta atvira repozicija, lūžis fiksuotas dviem Kiršnerio vielomis, alkūnė imobilizuota, pooperacinėse rentgeno nuotraukose – fragmentų ir implantų padėtis gera. 5 sav. po operacijos pastebėta Kiršnerio vielos migracija, pacientas stacionarizuotas implantų eliminacijai. Lūžis stabilus, todėl revizinė operacija neatlikta, nuspręsta stebėti pacientą kas 6 mėn. 6 mėn. po operacijos pacientas skundėsi skausminga fleksija ir ekstenzija, visiškai ribota supinacija ir pronacija. Rentgeno nuotraukose ir KT – pilno stipikaulio galvutės sugijimo nematyti, alkūnkaulyje matoma egzostozė nusitęsianti link stipinkaulio proksimalinės dalies; stipinkaulyje matomos subchondrinės cistos, hiperosifikacija ir deformacijos požymiai. MRT – nesugijusios stipinkaulio galvos potrauminiai pakitimai, antrinės avaskulinės nekrozės požymiai, žastikaulio epifizės srityje reaktyvūs kraujotakos sutrikimai. Rezultatai Abiem pacientams dėl alkūnės skausmo, sumažėjusios judesių amplitudės, atsižvelgiant į radiologinius pokyčius, nuspręsta atlikti stipinkaulio galvos rezekciją, siekiant sustabdyti potrauminių pokyčių progresavimą, žastikaulio galvutės pažaidą ir atkurti dilbio rotacinę funkciją. Po operacijos pacientams fleksija ir ekstenzija neskausminga, neribota. Dilbio pronacijos ir supinacijos amplitudė 1-ajai pacientei atsistatė pilnai, 2-ajam pacientui matyti ryškus funkcijos pagerėjimas, tačiau pilna amplitudė išlieka ribojama kontraktūros. Abiems pacientams radiologiškai stebima nežymi alkūnės sąnario valgus deformacija. 12 mėn. po mergaitės operacijos ir 6 mėn. po berniuko operacijos riešo judesiai nesutrikę, neskausmingi, radiologiškai stipinkaulio migracijos proksimalyn ir riešo sąnario kongruentiškumo pažeidimo nematyti. Išvados, rekomendacijos • Stipinkaulio galvos rezekcija gali pagerinti alkūnės sąnario funkciją ir sumažinti skausminį sindromą, esant lūžių komplikacijoms; • Galimos komplikacijos riešo sąnaryje po stipinkaulio galvos rezekcijos; • Prieš atliekant stipinkaulio galvos rezekciją būtina apsvarstyti galimus alternatyvius gydymo metodus. Vengti skuboto sprendimo galvos šalinimui, kadangi procesas yra negrįžtamas.

There is low-certainty evidence on the impact of extended pharmacological prophylaxis on venous thromboembolism-associated morbidity and mortality. The aim of this study was to determine the efficacy and safety of extended prophylaxis after major abdominopelvic surgery for the prevention of clinically relevant venous thromboembolism after hospital discharge.