Outcomes of long-arm casting versus double-sugar-tong splinting of acute pediatric distal forearm fractures.

INTRODUCTION: The traditional treatment after closed reduction of distal radius (DR) and distal both bone (DBB) forearm fractures has been application of a long-arm cast (LAC) or a short-arm cast (SAC). Splinting is another option that avoids the potential complications associated with casting. The purpose of this study is to evaluate the maintenance of reduction of DR or DBB fractures placed in a double-sugar-tong splint (DSTS) compared with a LAC in a pediatric population. METHODS: This is an IRB-approved, prospective, randomized trial. Patients aged 4 to 12 years with DR or DBB fractures treated at a single institution between 2010 and 2012 were enrolled. After reduction, fractures were placed into either a LAC or a DSTS. Radiographs were reviewed at initial injury, postreduction, and at set intervals for angulation, displacement, and apposition, as well as cast index and 3-point index. The DSTS was overwrapped into a cast after week 1. The immobilization device was changed to a SAC at week 4 or 6. Total duration of immobilization was 6 to 8 weeks. RESULTS: Seventy-one patients were enrolled with 37 in the LAC and 34 in the DSTS. Average age was 8.73 years (range, 4 to 12) with 43 being males. There were 28 isolated DR and 43 DBB fractures. There were no week-to-week differences between the 2 groups in regards to sagittal alignment, coronal alignment, apposition, or displacement. Sagittal alignment at immediate postreduction and week 2 showed that the DSTS was slightly better (average 2.0 vs. 5.0 degrees, respectively, P=0.04). For the entire treatment period there was an increased risk of loss of reduction of ≥10 degrees in the LAC group versus the DSTS group (7 patients vs. 2 patients, respectively, P=0.0001), and of meeting the criteria for remanipulation (10 patients vs. 5 patients, respectively, P=0.01). At cast removal, there was no difference between groups. CONCLUSIONS: Although there were significant differences between the 2 groups with regards to risk of reduction loss, the DSTS and LAC were comparable in maintenance of reduction at the time of cast removal. Both the DSTS and LAC are appropriate immobilization devices for these pediatric fractures. LEVEL OF EVIDENCE: Level II-prospective, comparative study.

Infections following arthroscopic anterior cruciate ligament reconstruction.

PURPOSE: Infection after anterior cruciate ligament (ACL) reconstruction is a serious but uncommon complication. Optimal management has not been established. The purpose of our case series was to review our experience and published reports to identify risk factors, evaluate physical and laboratory findings, compare different treatments, and assess clinical outcomes. METHODS: Retrospective review of all the arthroscopic ACL reconstructions performed at our institution between 1994 and 2002. Patients with intra-articular infections were evaluated and, when available, comparisons were made between patients with extra-articular infections and uncomplicated postoperative ACL reconstructions. RESULTS: Eleven postoperative infections were identified, all in patients who had hamstring autograft. Previous knee surgery, especially previous ACL reconstruction and tibial ACL graft fixation with a post and washer, was associated with increased infection. Laboratory data revealed elevated erythrocyte sedimentation rate (average, 67), C-reactive protein (average, 14), and intra-articular blood cell count (average, 52,000). All infections were eradicated with serial arthroscopic incision and drainage (average, 2.4 procedures) and intravenous antibiotics (duration, 14 to 42 days). The graft was retained in 10 of 11 patients. At an average follow-up of 22 months, the average Lysholm functional knee score was 71.6 out of 100 points (range, 36-99). Of the 5 patients with fair/poor results, the most common chief complaint was pain and stiffness. CONCLUSIONS: Long-term goals for treatment of patients with postoperative ACL infections are to protect the articular cartilage and to maintain knee function. Timely initiation of treatment, including joint lavage, debridement, and antibiotics, are essential to treatment. Graft and hardware retention can successfully accomplish these long-term goals. However, if early clinical response is not acceptable, strong consideration should be given to expedient graft and hardware removal. Excellent outcomes can be obtained, but results are usually lower than with uncomplicated cases. LEVEL OF EVIDENCE: Level IV, case series.

Coxa saltans externa treated with Z-plasty of the iliotibial tract in a military population.

Coxa saltans, or snapping hip, can be attributable to a number of causes. Coxa saltans externa typically occurs when the thickened portion of the iliotibial band snaps over the greater trochanter as the hip is flexed. This condition generally resolves with a course of nonoperative treatment. We have treated three patients with Z-plasty of the iliotibial band, which has the highest published success rate in the English language literature. Only one of three patients was able to return to full activities postoperatively. In our small series, this method of surgical treatment in an active duty military population yielded less than optimal results.

The "bluie," a simplified method for applying a vacuum-assisted closure dressing in residual limbs and complex war wounds.

An impervious plastic stockinet can facilitate application of a vacuum-assisted closure dressing in complex, traumatic wounds. This article reviews our technique.

Acute operative stabilization versus nonoperative management of clavicle fractures.

We conducted a prospective, randomized study to determine if patients with midshaft clavicle fractures would benefit from immediate operative stabilization with a modified Hagie pin in comparison with a matched group treated with nonoperative therapy. At a level II trauma center, patients with closed midshaft clavicle fractures were prospectively randomized to receive either operative or nonoperative treatment. Fifty-seven (29 operative, 28 nonoperative) patients were enrolled in the study. Operative patients underwent open reduction and internal fixation of the clavicle using a modified Hagie pin; nonoperative patients were treated with a sling for comfort. All patients were followed at regular intervals for 1 year. They were evaluated for radiographic healing and complications and were scored with the Single Assessment Numeric Evaluation and L'Insalata instruments. Injury severities and radiographs were not statistically significantly different between the 2 groups. Functional scores in the operative group were slightly higher at 3 weeks, and the nonoperative group had slightly higher scores at 6 months and 1 year. The only statistically significant difference between the groups was at 3 weeks. Percentage follow-up at 1 year was 93% for the operative group and 82% for the nonoperative group. One patient in each group developed a nonunion, and 1 patient in each group had a refracture. Complications were higher in the operative group, and most were related to pin prominence at the posterior shoulder. Results of this study suggest that, though patients with midshaft clavicle fractures had higher functional scores at short-term follow-up after internal fixation, functional scores were similar at 6 months and 1 year. In addition, internal fixation with a modified Hagie pin was associated with a higher complication rate.

Foot fractures frequently misdiagnosed as ankle sprains.

Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.