The Reverse Oblique Supracondylar Humerus Fracture: Description of a Novel Fracture Pattern.

BACKGROUND: Sagittal profile descriptions of supracondylar humerus fractures are limited. We describe a reverse oblique (RO) pattern in which the distal fragment has a prominent anterior spike that is displaced posterior to the proximal fragment. This pattern presents a challenge during closed manipulation utilizing traditional reduction maneuvers. The purpose of this study is to compare the clinical and radiographic characteristics of the RO and non-RO patterns of supracondylar humerus fractures. We hypothesized that the RO pattern would be associated with greater soft tissue trauma. METHODS: Retrospective evaluation of operative supracondylar humerus fractures treated at a tertiary pediatric hospital from 2014 to 2016. Patients were categorized into RO and non-RO groups for analysis. Associated neurovascular injuries were compared between groups. RESULTS: Two hundred ninety-nine consecutive patients were reviewed. The RO fracture pattern was seen in 12 patients. All displaced RO fractures were able to be closed reduced with a modification to the traditional reduction sequence. Overall cohort rates of preoperative soft tissue injury included antecubital ecchymosis 16.8%, nerve palsies 15%, and vascular compromise 6.4%. Compared with non-RO fractures, the RO fracture group had significantly higher rates of anterior interosseous nerve (AIN) palsies (P=0.013), antecubital ecchymosis (P=0.018), and compartment syndrome (P=0.043). When comparing RO with non-RO type II fractures, there were no differences in soft tissue injury (P=0.439). Compared with non-RO type III fractures, RO type III fractures had higher rates of AIN injury (P=0.047), antecubital ecchymosis (P=0.007), and overall soft tissue injury (P=0.009). CONCLUSIONS: This study introduces a previously undescribed supracondylar humerus fracture subtype: the RO fracture. We found increased rates of soft tissue compromise including antecubital ecchymosis and AIN palsy in this fracture type. Further, traditional reduction methods proved to be ineffectual for this fracture pattern. We utilized a simple modification that allowed for closed reduction and percutaneous pinning of displaced RO fractures. LEVEL OF EVIDENCE: Level III-prognostic.

Access to Orthopedic Care post Medicaid Expansion Through the Affordable Care Act.

BACKGROUND: As of January 2017, 32 states have decided to expand Medicaid through the Patient Protection and Affordable Care Act. The uninsured rate in the United States has decreased, but does the increased coverage translate to increased access to outpatient orthopedic care? Through a simulated patient telephone survey, this study aims to evaluate access to orthopedic surgeons for Medicaid patients in Louisiana. METHODS: A comprehensive list of potentially eligible orthopedic surgeons in the state of Louisiana was obtained from an online public database managed by the Louisiana Medicaid website (lamedicaid.com). This list represented all orthopedic surgeons that received a Medicaid payment within the six months prior to February 1st, 2017 (August 1st, 2016-January 31st, 2017). Using an internet search, we found that 309 orthopedic surgeons listed met the inclusion criteria and were practicing in 93 different clinical practices. Because several orthopedists practiced in the same group practice, and some practiced in multiple practices, we sampled unique clinical practices as opposed to individual providers. One telephone call was made to each practice in an attempt to secure an appointment for a simulated Medicaid patient. The average number of orthopedic surgeons per practice was 3.4, with the majority of practices (60%) being private practices with only one surgeon. RESULTS: Of the 93 practices in the study, only 17 (18.3%) offered an appointment. The 17 practices represented 41 orthopedic surgeons (13.3%) that were willing to accept new Medicaid patients. That number decreased to 22 (7.1%) if you remove the orthopedic surgeons practicing at safety-net facilities. CONCLUSION: The results suggest that although Medicaid expansion has decreased the uninsured rate, access to outpatient orthopedic care for Medicaid patients in Louisiana is still significantly limited.

Knee Range of Motion as a Discriminatory Tool Indicating Potential Meniscal Tears.

BACKGROUND: Primary care physicians often encounter patients with knee pain and are faced with the dilemma of whether to refer patients to a specialist. Meniscal tears are the most common intraarticular knee injury but are challenging to accurately diagnose because of a lack of quantitative, accurate, and easy-to-administer tests. We conducted a retrospective medical record review to evaluate whether measurement of knee range of motion (ROM) via goniometry could discriminate between healthy and meniscus-altered knees. METHODS: A total of 110 adult patients met the inclusion criteria: age ≥18 years; no history of contralateral knee pain, injury, or surgery; ROM data collected using a goniometer on both knees at the time of diagnosis; and a confirmed diagnosis of meniscus tear via magnetic resonance imaging. The following variables were obtained from medical records: age, sex, body mass index (BMI), ROM for both knees, surgical treatment, insurance coverage, Ahlbäck x-ray grades, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Oxford Knee Score (OKS). RESULTS: The majority of patients (96.4%) exhibited a ≥10° difference in flexion between asymptomatic and symptomatic knees. No significant relationships were observed between age, BMI, and the decision to undergo surgery and the difference in flexion or extension ROM. Both the WOMAC and the OKS were significantly correlated with the degree of loss of flexion ROM. CONCLUSION: The results suggest that knee flexion ROM may be a valuable tool for determining which patients presenting with new-onset ipsilateral knee pain should be referred to a specialist. Further investigation to determine the reliability and accuracy of knee ROM as a screening measure is warranted.