Reliability of Casting Indices Among Members of an Orthopaedic Surgery Residency.

BACKGROUND: Multiple casting indices have been described to evaluate the adequacy of cast placement in pediatric distal forearm fractures. The aim of this study was to determine the intrarater and interrater reliability of the measurements of 5 common casting indices among members of an orthopaedic surgery residency program. The cast index, 3-point index, gap index, padding index, and Canterbury index were evaluated. METHODS: This was a single-center prospective cohort reliability study that included 12 members of an orthopaedic surgery residency. Participants were placed into 1 of 4 groups by level of training: physician assistants, junior residents, senior residents, and attending orthopaedic surgeons. Twelve radiographs of casted pediatric distal forearm fractures were measured by each participant on 2 separate occasions. Statistical analysis using the intraclass correlation coefficient was used to determine the intrarater and interrater reliability. RESULTS: The cast index was the only casting index to meet our criteria for good intrarater and interrater reliability. CONCLUSION: Continued use of the cast index as a tool to assess pediatric distal forearm cast application is supported by this study. LEVEL OF EVIDENCE: Level 2.

Gunshot-associated Fractures in Children and Adolescents Treated at Two Level 1 Pediatric Trauma Centers.

INTRODUCTION: Gunshot injuries are a potentially significant cause of morbidity and mortality in the pediatric population. The objective of this study was to evaluate the epidemiology, fracture locations, associated injuries, types of treatment, and complications of gunshot-associated fractures in children and adolescents treated at two level 1 trauma centers. METHODS: The clinical and radiographic records of all children and adolescents who had a gunshot-associated fracture treated at 1 of 2 level 1 pediatric trauma centers between January, 2005, and April, 2013, were reviewed. The following characteristics were recorded: patient age and sex, type of weapon, fracture location, presence of neurovascular injury or other associated injuries, antibiotic treatment, method of stabilization, duration of hospital stay, complications, and need for subsequent procedures. RESULTS: Forty-nine patients with 58 fractures were identified; 9 patients had multiple fractures. The 41 males and 8 females had an average age of 12.2 years (range, 1 to 18 y). The tibia and femur were the most common sites of fracture (19% each), followed by the small bones of foot (4%) and the fibula (4%). Most of the fractures (71%) were treated nonoperatively. Nearly half (47%) of the patients had additional injuries, including abdominal or genitourinary injuries, neuropraxia or nerve injuries, and vascular injuries. Two patients (4%) developed infections (1 superficial and 1 deep) that required multiple irrigation and debridement procedures. Three patients developed compartment syndrome, and 4 patients had vascular injuries requiring repair. Nearly a third of patients (35%) had fractures or complications that required additional operative procedures. CONCLUSIONS: This large retrospective study highlights the significant morbidity of fractures caused by gunshots. Although the overall infection rate was low and most of these fractures were successfully treated nonoperatively, many of the patients required an additional operative procedure and nearly half had additional nonorthopaedic injuries. This emphasizes the necessity of coordination among emergency, general surgeons, intensivist, and orthopaedic surgical teams. LEVEL OF EVIDENCE: Level IV­retrospective case series.

The effect of immobilization devices and left-foot adapter on brake-response time.

BACKGROUND: The ability to perform an emergency stop is essential for safe driving and can be represented by total brake-response time, reaction time, and braking time. Immobilization of the lower extremities is routinely performed for a variety of musculoskeletal conditions. This study sought to investigate the effect of immobilization with a left-foot driving adapter, a controlled-ankle-motion device, and a short leg cast on braking times. Our hypothesis was that there would be a significant difference in braking-time values between individuals utilizing a left-foot driving adapter or immobilization device and control individuals wearing normal footwear. METHODS: A prospective, observational study was conducted to assess the effect of the immobilization devices on braking times. A driving simulator was used to assess total brake-response time, reaction time, and braking time in thirty-five volunteers. Volunteers were assessed while (1) wearing normal footwear (control group), (2) wearing a controlled-ankle-motion boot, (3) wearing a removable short leg cast, and (4) employing a left-foot driving adapter. RESULTS: The mean total brake-response time was significantly increased as compared with that of the control group in all three study groups. The mean reaction time was significantly increased for the short leg cast and controlled-ankle-motion groups as compared with reaction time in the control group. The mean braking time was significantly increased in the controlled-ankle-motion and left-foot driving-adapter groups as compared with braking time in the control group. CONCLUSIONS: Total brake-response time while wearing a controlled-ankle-motion boot or a short leg cast or while utilizing a left-foot driving adapter is significantly increased, or worsened, as compared with the response time while wearing normal footwear. This information may prove valuable to physicians when counseling patients on when it may be safe to return to driving.