Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

Diminished coordination skills may predispose injury to lesser toe fractures-a pilot study.

INTRODUCTION: Lesser toe fractures of the foot are a common lower extremity injury. The common mechanism of injury is a direct impact of force on the toe due to a collision of the toe with an object, often related as accidental injury or clumsiness. MATERIALS AND METHODS: This is a case-control study. We compared patients with lesser toe fractures to a healthy control group. We used a motor imagery tool to evaluate the proprioception and function of the pre-motor, center of motion planning cortex. Forty images of the left/right feet in various positions were incorporated into a dedicated software application. Participant reaction time and accuracy of recognition were recorded. RESULTS: Forty-two adult participants (20 with lesser toe fractures and 22 in the control healthy group) were included in the study. There was no difference in the participant's self-perception of clumsiness or involvement in activities that are related to better coordination. There was no difference in the accuracy or the reaction time in the motor imagery tool. The control group was significantly (p < 0.05) more accurate in recognizing their dominant side, whereas the fracture group was more accurate in recognizing their non-dominant side. CONCLUSIONS: Our findings do not support the premise that diminished coordination skills may predispose to injury to lesser toe fractures. Our findings may suggest that mixed laterality (hand/foot) is related to lesser toe fractures and thus may be related to clumsiness. Whether these alterations in perception bare merit in other types of physical injuries has yet to be explored.

Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Although point-of-care ultrasound (POCUS) has been shown to be useful in the identification of both pediatric and adult long-bone fractures in the emergency setting, radiography remains the standard of care. Emergency physicians are often faced with the dilemma of how to evaluate and treat the child with lower leg injury and physical examination concerning for fracture but no readily identifiable fracture line on radiography. CASE REPORTS: We present four cases in which POCUS was used to diagnose a radiographically occult fracture of the proximal tibia in young children. This is the first case series of occult fracture of the tibia diagnosed with POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can demonstrate evidence of fracture even after unremarkable radiography is obtained, and POCUS findings consistent with fracture might allow for more effective guidance on discharge.

Trampoline-related Injuries in Children: A Tertiary Pediatric Center Experience in Israel.

BACKGROUND: The growing popularity of trampoline jumping in the past years has led to an increase in trampoline-related injuries. The risk is particularly high in large trampoline parks, which are attended by many individuals of various sizes and ages. OBJECTIVES: To describe a tertiary pediatric center experience in Israel. METHODS: The database of a tertiary pediatric medical center was retrospectively reviewed for all trampoline-associated admissions to the emergency department in 2015-2018. Data were collected on patient demographics and injury characteristics with an emphasis on type and venue. RESULTS: Of the 23,248 admissions for orthopedic trauma during the period, 244 children were admitted for 246 trampoline-related injuries. Injuries involved the lower limb in 130 children (53%), upper limb in 87 (36%), spine in 20 (8%), and other sites in 9 (3%). Almost half of the injuries (113/246, 46%) were fractures, 27% required either closed or open reduction in the operating room. Large trampoline centers were responsible for half of the cases. CONCLUSIONS: Trampoline injuries accounted for 1.05% of all emergency department admissions at a tertiary pediatric hospital in 2015-2018. Nearly half of the trampoline-related injuries were fractures. Large trampoline centers pose a potential risk for more serious injuries. We raise awareness of the risks of trampoline jumping, considering increasing popularity of trampoline parks, and encourage the authorities to implement safety regulations.

[MULTIPLE GIANT CELL TUMOR OF TENDON SHEATH: A CASE REPORT OF THREE LESIONS ON THE SAME FLEXOR TENDON].

INTRODUCTION: We present a case report of a triple location Giant Cell Tumor of tendon sheath appearance on the same flexor tendon sheath of a single digit. There have been scarce descriptions of multiple Giant Cell Tumors of tendon sheath. Multiple tumors may predispose patients to a higher recurrence rate; therefore, recognition and treatment of this rare entity is important.

Arthroscopic knee debridement in osteoarthritis in the older age can be satisfactory.

Introduction: Knee arthroscopy is one of the treatments for knee pain. In recent years, the use of knee arthroscopy in the treatment of osteoarthritis was challenged by several randomized-controlled trials, systematic reviews and meta-analyses. However, some design flaws are making the clinical decision harder. This study specifically explores the patient satisfaction from these surgeries to aid in clinical decision. Hypothesis: Knee arthroscopy can relieve symptoms and delay further surgical treatment in the older age. Patients & methods: Fifty patients accepted participation and were invited to a follow-up examination eight years post knee arthroscopy. All patients were above age 45 and diagnosed with degenerative meniscus tear and osteoarthritis. The patients filled follow-up questionnaires of function (WOMAC, IKDC, SF-12) and pain. The patients were asked to appreciate if they would have repeated the surgery retrospectively. The results were compared to a previous data base. Results: Thirty-six patients (72%) reported satisfaction of 8 and above (scale of 0-10) from the surgery and would have repeated it. A higher SF-12 physical score pre-surgery predicted a higher satisfaction rate (p = 0.027). Patients who were more satisfied from the surgery improved post-surgery in all parameters compared with the less-satisfied group (p < 0.001). Patients above the age 60 had similar parameters pre- and post-surgery compared with patients under the age 60 (p > 0.05). Conclusions: Patients between the ages 46-78 with degenerative meniscus tear and osteoarthritis felt they benefited from knee arthroscopy in an eight-year follow-up and would repeat the surgery. Our research may help with better patient selection and suggest knee arthroscopy can relive symptoms and delayed further surgical treatment for the older patient with clinical symptoms and signs of meniscus related pain, mild osteoarthritis, and failed conservative treatment. Level of evidence: IV.

Ulnar Superficialis Slip Resection Versus Radial Superficialis Slip Resection: A Biomechanical Pilot Study.

BACKGROUND: There are numerous clinical scenarios during which the surgeon contemplates whether the radial or ulnar slip of the flexor digitorum superficialis (FDS) should be sacrificed. To date no study has assessed the point of failure of each one of the FDS slips in each digit, aiding the avid surgeon in deciding which slip to sacrifice. METHODS: A total of 41 digits were assessed, each digit was dissected, and a specimen containing the denuded bone of the middle phalanx with the attachments of the ulnar and radial FDS slips was obtained. An Instron 4502 device was utilized to biomechanically assess the point of failure of each slip of each digit. RESULTS: There was no statistical difference between ulnar and radial slip point of failure when compared across all digits and subjects. There was no statistical difference between male and female subject's specimens. The point of failure was higher in the ulnar slips of the second and third digits, whereas the point of failure was higher in the radial slips of the fourth and fifth digits. CONCLUSIONS: Sacrifice of a FDS slip may cause loss of grip strength. In several clinical scenarios one may be faced with the dilemma which FDS slip to sacrifice. Our findings show this is not an arbitrary choice. Hand surgeons should keep our findings in mind when deciding which slip to sacrifice, in effort to preserve function and strength in the injured hand.

The influence of early virtual reality intervention on pain, anxiety, and function following primary total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most popular surgeries in the orthopedic field. One of the reasons for a failed TKA is pain and difficulty to return to normal function. A pain control method that is becoming more and more popular is the use of virtual reality (VR). We aimed to examine VR intervention in the immediate post-operative physiotherapy following TKA. METHODS: This prospective randomized-controlled study recruited a total of 55 patients undergoing primary TKA in a single institute, operated by three surgeons. They were assigned either study group or control group. Both groups were treated with conventional physiotherapy and CPM equipment (Continuous passive motion device), the study group received additional VR modality. Both groups completed a series of questionnaires prior and after the intervention: State-Trait Anxiety Inventory (STAI) questionnaire (used to diagnose anxiety), Visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (knee function score). RESULTS: The average age was 70 years-old with equal distribution of male and female. Both groups showed a decrease in pain and anxiety following the intervention (p value < 0.05) but there was no difference between the groups (p value > 0.05 for all parameters). The was no difference in the WOMAC scores in the six-month post-operative examination between groups (p-value = 0.653). CONCLUSIONS: Virtual reality intervention in the immediate post-operative period following total knee arthroplasty decrease pain and anxiety but did not influence the pain, anxiety, and long-term function results more than conventional physiotherapy.

Retained Scalpel Blade in the Knee Joint 15 years After Knee Arthroscopy: A Case Report.

CASE: A 48-year-old man presented with persistent right knee pain 15 years after an arthroscopic partial meniscectomy. Right knee radiography was remarkable for a retained scalpel blade in the knee joint. The retained scalpel blade was completely removed from the affected knee arthroscopically; however, the patient's knee pain did not improve with 6 weeks of physically therapy. CONCLUSIONS: Arthroscopy surgeons should be cognizant of the risk for retained implants and emphasize the importance of a postprocedure surgical equipment count, and the merits of an x-ray if surgical count discrepancies are detected, or the patient has persistent joint pain despite rehabilitation.

Age-adjusted treatment of cervical intraepithelial 1 lesions by superficial or regular loop excision of transformation zone.

BACKGROUND: The loop electrosurgical excision procedure (LEEP) is one of the treatments for cervical intraepithelial neoplasia 1 (CIN1). One of the risks of LEEP is preterm birth. We evaluated final pathological diagnoses following LEEP as treatment for CIN1 lesions, for procedures in which cone height was determined by patients' age. METHODS: A retrospective study of 329 women diagnosed with CIN1 on a cervical biopsy and treated by LEEP. In patients under age 35 years, a thin LEEP COIN was performed, and in women over 35 years, a regular LEEP was performed. RESULTS: The final pathological diagnosis was CIN2 and CIN3 in 14.6% of the women. The average excision height was 0.64 cm in women aged under 35 years, 0.82 cm in women aged 36-45 years, and 0.96 cm in women older than 46 (P<0.0001). Comparing excision height less than 0.8 cm to excision height above 0.9 cm, complications of the procedure, positive margins rates and recurrence rates were similar. CONCLUSIONS: Among women of childbearing age, the performance of a LEEP procedure with smaller cone height appeared equivocal in achieving correct pathological diagnoses and low recurrence. To avoid increasing the risk of premature delivery, the excisional depth should be adjusted to age and fertility status.