Transphyseal Fracture of the Distal Humerus.

Transphyseal fractures of the distal humerus often occur in children younger than 4 years as a result of birth trauma, nonaccidental trauma, or falls from a low height. It is important to identify and treat these injuries in a timely manner to ensure successful management. Most transphyseal fractures of the distal humerus are treated with closed reduction and percutaneous pinning with the aid of an elbow arthrogram. The most common complication following a fracture is cubitus varus caused by growth arrest, malunion, or osteonecrosis of the medial condyle. Normal carrying angles may be restored through corrective lateral closing wedge osteotomy.

Hand Fractures-Management and the Complications That Inevitably Occur: Metacarpal Fractures.

Metacarpal fractures are among the most common hand fractures. To properly manage these injuries, surgeons must understand the anatomy, biomechanics, clinical assessment, surgical and nonsurgical treatment options, and potential complications. Metacarpal head fractures often require surgical treatment to restore the joint surface by using a variety of techniques. Metacarpal neck fractures are usually stable injuries that do not require surgical intervention, but surgeons must know when surgical intervention is indicated. Fractures of the metacarpal shaft can be treated surgically and nonsurgically and may be associated with large bone defects or soft-tissue injuries that require careful consideration. Finally, fractures involving the carpometacarpal joints must be promptly managed to avoid long-term complications, potentially requiring salvage procedures.

Proximal Interphalangeal Joint Fractures.

Multiple fracture patterns can occur around the proximal interphalangeal joint and require surgeons to have a thorough understanding of the anatomy, clinical and radiographic examination, common fracture patterns, surgical and nonsurgical treatment options, and potential complications. Proximal phalangeal condylar fractures are typically managed surgically, because even nondisplaced fractures have a propensity for displacement. Middle phalangeal base fractures most commonly present as a volar lip fracture with or without dorsal subluxation or dislocation. Treatment options include extension block splinting or pinning, transarticular pinning, open reduction and internal fixation, external fixation, volar plate arthroplasty, and hemihamate arthroplasty. Less common fractures include dorsal lip fractures with or without volar subluxation or dislocation (the central slip fracture), lateral plateau impaction or avulsion injuries, and pilon fractures. The main goals in the management of middle phalangeal base fractures are to restore articular congruency and initial early range of motion, which are more important than obtaining an anatomic reduction.

Pediatric Phalanx Fractures.

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

Developmental Anatomy of the Radial Bow in Pediatric Patients Using 3D Imaging.

BACKGROUND: While radial bow shape is well characterized in adults, its development in children is not well understood. Previous studies on the radial bow use radiographs, thus, rotational positioning of the forearm could alter bowing measurements. This study used 3D imaging to better assess the pediatric radial bow. METHODS: Computed tomography scans from the New Mexico Decedent Image Database were obtained for ages 2 to 16 (females) and 18 (males) (n=152). 3D models were generated using Slicer and Rhino software. Length of the entire radial bow (bicipital tuberosity to sigmoid notch), maximum radial bow, location of the maximum radial bow (bicipital tuberosity to the point of maximum bowing), and distal, middle, and proximal third radial bows were measured. RESULTS: The length of the entire bow increased with age, with a strong correlation with age ( r =0.90, P <0.01). The maximum bow increased with age, with a strong correlation with age ( r =0.78, P <0.01). The maximum bow normalized to the length of the entire bow increased mildly with age, mean 0.059 ± 0.012 ( r =0.24, P =0.0024), but seems to plateau around age 8. The location of the maximum bow increased with age ( r =0.85, P <0.01). The normalized location of the maximum bow remained constant between ages, with a mean of 0.41 ± 0.10 ( r =0.12, P =0.14). The normalized distal third bow mildly increased with age ( r =0.34, P <0.01), the normalized middle third bow mildly increased with age ( r =0.25, P <0.01), and the normalized proximal third bow remained constant between ages ( r =0.096, P =0.24). CONCLUSIONS: Normalized values for maximum, distal third, and middle third radial bow increase with age, while normalized values for location and proximal third radial bow remain relatively constant, suggesting the proportional shape of the radius changes during development, although qualitatively plateaus after age 8. LEVEL OF EVIDENCE: Retrospective comparative study, Level-III.

The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts.

PURPOSE: The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. METHODS: We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. RESULTS: For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. CONCLUSIONS: This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Telerehabilitation Use With Spinal Cord Injury: Occupational Therapists' Perspective.

IMPORTANCE: Telerehabilitation provides people with spinal cord injury (SCI) an alternative mode of accessing specialized health care. Further research on occupational therapy practitioners' perspectives of telerehabilitation may provide additional evidence for clinical practice implementation. OBJECTIVE: To explore urban occupational therapists' perspectives on the benefits of and barriers to telerehabilitation use with SCI. DESIGN: A qualitative study design using a demographic questionnaire and a single, individual semistructured interview. Thematic analyses included member checking, constant comparative analysis, triangulation, and self-description and self-reflexivity. SETTING: Residential and community settings. PARTICIPANTS: Six occupational therapists with a range of experience in SCI rehabilitation were recruited using purposeful sampling. RESULTS: Six participants were interviewed, and four primary themes emerged: (1) communication, (2) personal factors, (3) benefits, and (4) barriers. CONCLUSIONS AND RELEVANCE: Telerehabilitation offers numerous potential benefits for SCI intervention. This study provides an understanding of practitioner concerns and potential barriers to use. The results indicate that a hybrid model incorporating both in-person and distance-based treatment is likely optimal. What This Article Adds: Our results provide information that addresses practitioner concerns and recommendations for the use of telerehabilitation with people with SCI. As practitioner concerns are identified and addressed, telerehabilitation may increase in the U.S. health care system, potentially facilitating an alternative treatment delivery method for underserved populations.

A 5-Year Review of the Designated Leadership Positions of the American Society for Surgery of the Hand (ASSH).

PURPOSE: Despite near equal representation of women in medical schools since 2008, the percentage of women in surgical subspecialties has remained low. Hand surgery accounts for one of the highest percentages of women, at 19%. Ascension to leadership positions has not yet been fully studied among this group. Our study examined whether increased female representation translated to representation at different levels within the organization. METHODS: The 2014 to 2018 membership rosters were obtained from the American Society for Surgery of the Hand (ASSH) and compared by gender. Leadership and volunteer committee positions were evaluated as published in the annual ASSH Committee Reference Book. Leadership positions were defined as appointment to committee chair or Council or acceptance to the Young Leaders Program. Rates of engagement were compared for each of the leadership activities. When available, the time for advancement through various leadership positions was also analyzed by gender. RESULTS: Between 2014 and 2018, the percentage of female ASSH Active Members steadily increased from 11% to 14%. Engagement in early career activities such as committees and the Young Leaders Program also increased: committee positions from 16% to 17% and Young Leaders Program membership from 27% to 40% female representation across the same period. Relative to the overall number of eligible females in the society, women applied at a greater rate and achieved positions at an average of 2 years earlier than their male counterparts. CONCLUSIONS: There is a steady increase in the percentage of women within the ASSH. Female ASSH members applied for early career leadership positions at a higher rate and achieved these positions earlier than their male counterparts. This may indicate that future women leaders are appropriately supported in the organization. CLINICAL RELEVANCE: The ASSH has been committed to increasing gender and ethnic diversity. Early analysis demonstrates an increase in women surgeons' participation in early career leadership activities within the society.

ASSH 75 Years: An Update of Progress Over the Past 25 Years.

This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.

Transphyseal Humeral Separations: What Can We Learn? A Retrospective, Multicenter Review of Surgically Treated Patients Over a 25-Year Period.

PURPOSE: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. This multicenter study aimed to assess the various patient characteristics, injury patterns, treatments, outcomes, and complications in a large series of these injuries. METHODS: A retrospective review was conducted at 5 pediatric institutions to identify TPHS that were treated surgically in patients 0 to 3 years of age over a 25-year period. Patient demographics, mechanisms of injury, Child Protective Services involvement, diagnostic modalities, time to surgery, pin size and configuration, time to fracture union, and complications were recorded. RESULTS: A total of 79 patients aged 0 to 46 months, with a mean of 17.6 months, were identified and followed for a median of 57 days postoperatively. The most common mechanism of injury was accidental trauma (n=49), followed by nonaccidental trauma (n=21), cesarean section (n=6), and vaginal delivery (n=3). Child Protective Services were involved in 30 cases (38%). Additional injuries were reported in 19 of the patients; most commonly additional fractures including the humerus, rib, and skull fractures. All patients had elbow radiographs, whereas 4 patients had an elbow ultrasound and/or a magnetic resonance imaging. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intraoperatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), averaging utilization of 2.2 pins, and 2 patients underwent an open reduction. In total, 11 complications (14%) were noted, including decreased range of motion (n=4), cubitus varus/valgus (n=6), and need for additional surgery (n=1). No cases of avascular necrosis or physeal arrest were found. No losses of reduction were noted. CONCLUSIONS: This multicenter review provides the largest known demographic and outcomes data on TPHS. TPHS have excellent outcomes in the vast majority of patients when treated surgically. Nonaccidental trauma accounted for 27% of these injuries so it needs to remain high on the differential diagnosis. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Increased morphine requirements are predictive of acute compartment syndrome in adults with tibia fractures.

PURPOSE: The purpose of this study was to determine if increased milligram morphine equivalent (MME) requirements are a predictor of adult compartment syndrome in patients with tibia fractures. METHODS: A retrospective case-control study at a level-1 trauma center was performed over a five year period. Patients with tibia fractures who had acute compartment syndrome (ACS) requiring fasciotomy (n = 26) were matched with controls (n = 25). MME and pain scores were assessed within the 24 hour period preceding fasciotomy (cases) or fixation (controls). The presence or absence of the "6 Ps" and other clinical signs (diastolic blood pressure [DBP]) were also analyzed. RESULTS: Mean MMEs two hours before surgery was 25.5 ± 39.2 for ACS patients versus 8.6 ± 11.1 in controls (P = 0.043), while the mean pain scores were 8.8 ± 1.8 and 7.0 ± 2.5 (P = 0.049), respectively. Multivariable regression showed patients with ACS consumed 16.9 MME more than controls within two hours of surgery (P = 0.043) and scored 1.8 points higher on the numeric pain rating scale (P = 0.049). The mean number of clinical signs of compartment syndrome in the ACS patients was 3.4 ± 1.3 compared to 0.84 ± 0.85 in controls (P < 0.001). DBP was significantly higher in ACS patients within two to four hours of surgery (P = 0.005). CONCLUSION: Increased MME requirements and pain scores within two hours of surgery were significant predictors of ACS following tibia fracture. Increased narcotic requirements, pain scores, and DBP may be useful objective indicators of evolving ACS, in addition to the traditional signs, and should be closely monitored in the at-risk patient.

Understanding the Action of RARγ Agonists on Human Osteochondroma Explants.

Osteochondromas are cartilage-capped growths located proximate to the physis that can cause skeletal deformities, pain, limited motion, and neurovascular impingement. Previous studies have demonstrated retinoic acid receptor gamma (RARγ) agonists to inhibit ectopic endochondral ossification, therefore we hypothesize that RARγ agonists can target on established osteochondromas. The purpose of this study was to examine the action of RARγ agonist in human osteochondromas. Osteochondroma specimens were obtained during surgery, subjected to explant culture and were treated with RARγ agonists or vehicles. Gene expression analysis confirmed the up-regulation of RARγ target genes in the explants treated with NRX 204647 and Palovarotene and revealed strong inhibition of cartilage matrix and increased extracellular matrix proteases gene expression. In addition, immunohistochemical staining for the neoepitope of protease-cleaved aggrecan indicated that RARγ agonist treatment stimulated cartilage matrix degradation. Interestingly, cell survival studies demonstrated that RARγ agonist treatment stimulated cell death. Moreover, RNA sequencing analysis indicates changes in multiple molecular pathways due to RARγ agonists treatment, showing similarly to human growth plate chondrocytes. Together, these findings suggest that RARγ agonist may exert anti-tumor function on osteochondromas by inhibiting matrix synthesis, promoting cartilage matrix degradation and stimulating cell death.

Endoplasmic reticulum stress is induced in growth plate hypertrophic chondrocytes in G610C mouse model of osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a hereditary bone disorder most commonly caused by autosomal dominant mutations in genes encoding type I collagen. In addition to bone fragility, patients suffer from impaired longitudinal bone growth. It has been demonstrated that in OI, an accumulation of mutated type I collagen in the endoplasmic reticulum (ER) induces ER stress in osteoblasts, causing osteoblast dysfunction leading to bone fragility. We hypothesize that ER stress is also induced in the growth plate where bone growth is initiated, and examined a mouse model of dominant OI that carries a G610C mutation in the procollagen α2 chain. The results demonstrated that G610C OI mice had significantly shorter long bones with growth plate abnormalities including elongated total height and hypertrophic zone. Moreover, we found that mature hypertrophic chondrocytes expressed type I collagen and ER dilation was more pronounced compared to wild type littermates. The results from in vitro chondrocyte cultures demonstrated that the maturation of G610C OI hypertrophic chondrocytes was significantly suppressed and ER stress related genes were upregulated. Given that the alteration of hypertrophic chondrocyte activity often causes dwarfism, our findings suggest that hypertrophic chondrocyte dysfunction induced by ER stress may be an underlying cause of growth deficiency in G610C OI mice.

Monteggia Fracture-Dislocations in Children: History and Current Concepts and Management Schemes.

Since pediatric Monteggia fracture-dislocations were first described in 1814, they have been a complicated injury for orthopaedic surgeons to manage. These injuries typically consist of a fracture of the ulna with dislocation of the radial head. Unlike most pediatric injuries, Monteggia fracture-dislocations remodel very poorly, and the relationship between the radial head and the capitellum does not improve with time. As such, a more attentive approach is necessary. It is important for orthopaedic surgeons to be knowledgeable about the history of Monteggia fractures, common pathologic mechanisms, closed reduction techniques, surgical indications and methods, and outcomes, in addition to preferred management principles.

Hand Fractures in Children: When Do I Need to Start Thinking About Surgery?

Each year, a hand fracture is diagnosed in 24.2 of 100,000 children in Canada. Hand injuries are the most common fractures in children, making up approximately one fifth of all pediatric fractures. The incidence of hand fractures peaks between the ages of 10 and 14 years, with the highest frequencies observed among adolescent males. These increased frequencies coincide with the age at which most children begin playing contact sports, with sport-related injuries found to be the largest cause of adolescent fractures. The fifth digit is the most commonly injured digit, followed by the thumb. Phalangeal fractures constitute approximately 65% of pediatric hand fractures. Metacarpal fractures account for approximately 35% of pediatric and adolescent hand fractures, with 100 of every 100,000 children sustaining a fracture of the metacarpals. The decision to operate is related to many factors and depends on the age of the child and the location and nature of the fracture. The remodeling potential of pediatric bones factors largely into this decision because the phalangeal physis can contribute to bone growth and realignment via remodeling.

Management of Pediatric Forearm Fractures After Failed Closed Reduction.

Pediatric and adolescent forearm fractures account for nearly 40% of all fractures in childhood. The incidence of these fractures has increased over the past decade with a 10-fold increase in surgical intervention. A thorough physical examination of the upper extremity, with plain radiographs of the forearm, should be obtained to make the diagnosis. The primary modality of management for closed both-bone forearm fractures is a closed reduction if needed and long arm immobilization. Patients should be followed up weekly, for at least 3 weeks, to ensure maintenance of fracture alignment. Failure of closed management is a known complication of nonsurgical management, and providers should have a management algorithm to treat these patients. Re-manipulation and casting, or cast wedging, is warranted if the loss of reduction is noted early in the postreduction period. If closed reduction cannot be achieved, elastic stable intramedullary nailing is the management of choice with either single- or both-bone fixation. Potential complications of elastic stable intramedullary nailing include acute compartment syndrome, nonunion, dorsal radial sensory nerve neuritis, and extensor pollicis longus tendon rupture. In older children and adolescents with less remodeling potential, osteosynthesis with plate-and-screw fixation or hybrid fixation should be used.

Lateral Condyle Fractures in Children.

Lateral condyle fractures are the second most common fracture sustained in the pediatric elbow. Several classification systems are used to describe these fractures. The more recently described classifications help guide management, which is based on the degree of displacement and stability of the fracture. The goal of management is to obtain reduction of the articular surface and fracture union using closed or open reduction and fixation with Kirschner wires or screws. Motion should improve after the surgery. Complications, such as osteonecrosis and nonunion, are rare, but the treating surgeon should watch for these conditions.

Displaced Radial Neck Fractures: What Are My Options?

Pediatric radial head and neck fractures are uncommon injuries. Fractures are classified using the Judet system based on fracture angulation and displacement. Judet type I and II fractures can be managed nonsurgically with a short course of immobilization in a cast or splint without closed reduction. Most of these patients have an excellent prognosis and functional outcomes. Judet type III and IV injuries, as well as injuries that demonstrate a mechanical block to motion, should be closed reduced with the patient under conscious sedation or general anesthesia. Patients who undergo an unsuccessful closed reduction require closed or open reduction in the operating room. Closed reduction methods include the push and lever techniques with the use of Kirschner wires or Steinmann pins or intramedullary nails. Percutaneous fixation with wires or pins is needed only if the fracture fragment is determined to be unstable, whereas nails are left in place and require a second surgery for removal. Both methods have similar outcomes and an overall positive prognosis for patients. Open reduction and internal fixation should be avoided if at all possible given the higher incidence of wide-ranging complications.

Pediatric Ankle Fractures: When to Operate and When to Leave Alone?

Ankle fractures are a common pediatric orthopaedic injury and are the second most common site of physeal injury after the distal radius. Concerns regarding these injuries include the risk of premature physeal closure and intra-articular incongruence with subsequent degenerative changes. Salter-Harris type I and II injuries have high rates of premature physeal closure especially in those with a physeal gap greater than 3 mm and pronation-abduction injuries. The authors of this chapter recommend surgical management if acceptable alignment cannot be obtained with closed reduction. A residual physeal gap is not an appropriate sole indicator for surgical management. Salter-Harris type III and IV injuries also have high rates of premature physeal closure and can result in articular incongruence given their intra-articular nature. The authors of this chapter recommend surgical management of these fractures when intra-articular displacement is greater than 2 mm. Transitional fractures (ie, Tillaux and triplane) occur in older patients during distal tibial physeal closure. Fracture lines travel through the relatively weaker lateral tibial physis, which is the last to close in the transitional period. These intra-articular fractures with displacement greater than 2 mm should be managed surgically to anatomically reduce the articular surface and prevent early degenerative changes.

Tibial Shaft Fractures in Children: What to Do When Casting Fails?

Tibial shaft fractures in children can often be successfully managed with a well-molded cast that controls length, alignment, and rotation of the fracture. Acceptable alignment of tibial shaft fractures in children is less than 10° of coronal and sagittal angulation, 50% translation, and 10 mm of shortening. Fractures of the tibial shaft without an associated fibular shaft fracture may fall into varus malalignment despite initial adequate reduction and should be followed closely during the first 3 weeks after injury. Surgical treatment should be considered in adolescent patients and those with open fractures, comminuted fractures, and fractures that cannot be adequately reduced and stabilized with a cast. The predominant modes of surgical stabilization of tibial shaft fractures in children are external fixation or internal fixation with flexible intramedullary nails or via minimally invasive plate osteosynthesis; both methods have reliable results.