Effects of Videos and Therapeutic Music on Preoperative Anxiety and Postoperative Anxiety and Pain Levels in Boys Who Undergo Circumcision.

PURPOSE: This purpose of this study was to investigate the effects of having boys aged 5 to 10 years who will undergo circumcision surgery watch informative videos and listen to therapeutic music on preoperative anxiety, and postoperative anxiety, pain, and nausea and vomiting. DESIGN: This was a prospective and ranomized controlled study. MATERIALS AND METHODS: The sample consisted of 90 boys aged 5 to 10 years who underwent circumcision surgery. The boys included in the study were randomly divided into 3 groups of 30 using a computer program. The first group (group V) watched the video; the second group (group M) listened to the music, and the third group (group C) was the control group with usual care. Boys and their parents were not blinded to the grouping. FINDINGS: Heart rate.ßvalues were found to be statistically significantly lower compared to the control group at the 1st minute after local anesthesia in group V (P.ß=.ß.029), at the 5th minute after local anesthesia in group M (P.ß=.ß.030), and at the 10th minute after local anesthesia and after the surgery in both group V and group M (P.ß=.ß.001 and P.ß=.ß.010, respectively). Wong-Baker Faces Pain Rating Scale.ßscores of the control group measured at the 2nd postoperative hour were found to be significantly higher than those of group V (P.ß=.ß.018). Children's Fear Scale.ßscores of group V measured at the time of admission to the postoperative service were found to be significantly higher than those of group M and group C (P.ß<.ß.001). There was no significant difference between the groups in terms of additional analgesic use, nausea and vomiting percentages, and time to discharge. CONCLUSIONS: The results of this study revealed that having boys aged 5 to 10 years who will undergo circumcision surgery watch informative videos and listen to therapeutic music did not have any significant effect on their postoperative pain, fear, and anxiety levels. Further large-scale studies, which will also include children who will not undergo circumcision surgery, are needed to generalize this study's results to larger populations.

Golfers have greater preoperative and equal postoperative function when undergoing total knee arthroplasty compared to non-golfers.

BACKGROUND: Approximately 10% to 20% of patients with joint arthroplasties are golfers. The aim of this study was to assess if being a golfer is associated with functional outcomes, satisfaction or improvement in quality of life (QoL) compared to non-golfers following total knee arthroplasty. METHODS: All patients undergoing primary total knee arthroplasty (TKA) over a one-year period at a single institution were included with one-year postoperative outcomes. Patients were retrospectively followed up to assess if they had been golfers at the time of their surgery. Multivariate linear regression analysis was performed to assess the independent association of preoperative golfing status on postoperative function and health-related outcomes. RESULTS: The study cohort consisted of a total of 514 patients undergoing TKA. This included 223 (43.3%) male patients and 291 (56.7%) female patients, with an overall mean age of 70 (SD 9.5) years. The preoperative Oxford Knee Score (OKS) was significantly higher in golfers when adjusting for confounders (Diff 3.4 [95% CI 1 to 5.8], p = 0.006). There was no difference in postoperative outcomes between golfers and non-golfers. There was however a trend towards a higher Forgotten Joint Score (FJS) in the golfers (difference 9.3, 95% CI - 0.2 to 18.8, p = 0.056). Of the 48 patients who reported being golfers at the time of their surgery, 43 (89.6%) returned to golf and 88.4% of those were satisfied with their involvement in golf following surgery. CONCLUSIONS: Golfers had better preoperative and equal postoperative knee specific function compared to non-golfers. The majority of golfers returned to golf by one year and were satisfied with their involvement in the game. LEVEL OF EVIDENCE: III.

Strategies to expand corporate autonomy by the tobacco, alcohol and sugar-sweetened beverage industry: a scoping review of reviews.

BACKGROUND: Noncommunicable diseases contribute to over 70% of global deaths each year. Efforts to address this epidemic are complicated by the presence of powerful corporate actors. Despite this, few attempts have been made to synthesize existing evidence of the strategies used to advance corporate interests across industries. Given this, our study seeks to answer the questions: 1) Is there an emergent taxonomy of strategies used by the tobacco, alcohol and sugar-sweetened beverage (SSB) industries to expand corporate autonomy? 2) How are these strategies similar and how are they different? METHODS: Under the guidance of a framework developed by Arksey and O'Malley, a scoping review was carried out whereby six databases were searched in June 2021 to identify relevant peer-reviewed literature. To be included in this review, studies had to explicitly discuss the strategies used by the tobacco, alcohol, and/or sugar-sweetened beverage multinational corporations and be considered review articles aimed to synthesize existing evidence from at least one of the three industries. Eight hundred and fifty-eight articles were selected for full review and 59 articles were retained for extraction, analysis, and categorization. RESULTS: Results identified six key strategies the industries used: 1) influencing government policy making and implementation, 2) challenging unfavorable science, 3) creating a positive image, 4) manipulating markets, 5) mounting legal challenges, and 6) anticipating future scenarios. Despite these similarities, there are few but important differences. Under the strategy of influencing government policy making and implementation, for example, literature showed that the alcohol and SSB industries have been "privileged with high levels of participation" within international public health organizations. CONCLUSIONS: Understanding how industries resist efforts to control them is important for public health advocates working to reduce consumption of and death and diseases resulting from harmful commodities. Moreover, there is a greater need for the public health community to generate consensus about how to ethically engage or not engage with industries that produce unhealthy commodities. More studies are also needed to build the evidence base of industry tactics to resist regulation, particularly in the case of SSB, and in low-and middle-income countries.

Availability and advertising of electronic cigarettes in two Russian cities following implementation of comprehensive tobacco advertising restrictions.

INTRODUCTION: Electronic cigarettes (e-cigarettes) continue to gain popularity globally. Jurisdictions with comprehensive tobacco control policies, which limit the use and availability of combustible tobacco products but do not regulate e-cigarettes (as in Russia), may be vulnerable to the expansion of the e-cigarette market. METHODS: Using McNemar's test conducted in STATA, this observational study assessed changes between 2014 and 2016 in the availability of e-cigarettes across 239 retail outlets in Moscow and St Petersburg. Also, this study characterized the presence of retail advertising and promotion of e-cigarettes in 2016. RESULTS: Between 2014 and 2016, the availability and display of e-cigarettes increased within traditional tobacco product retail venues (27.6% in 2014 vs 51.9% in 2016; p<0.01). CONCLUSIONS: Observations indicate that there has been an increase in the proportion of retailers selling and displaying e-cigarettes.

Synovial fluid cell counts and its role in the diagnosis of paediatric septic arthritis.

PURPOSE: Clinical presentation of paediatric septic arthritis (SA) can be similar to other joint pathologies. Despite potential for infection in all major joints, most diagnostic criteria are based on values from the hip. This study identifies the best joint aspirate values in diagnosing SA in all joints. METHODS: In all, 166 patients who underwent 172 joint aspirations at the authors' institution between 01 September 2004 and 01 September 2014 were retrospectively identified. Recorded measures included age, sex, duration of symptoms, fever history, weight-bearing status, aspiration results, serum results and antibiotic administration. Patients were placed in the following four categories: 'culture confirmed SA' (C-SA), 'suspected SA' (S-SA), 'Other' and 'Other-rheumatologic' (Other-R), a subcategory of 'Other'. RESULTS: Most common sites of aspiration were the knee (55%) and hip (29%). Diagnostic grouping was as follows: C-SA = 44, S-SA = 45, Other = 83 (Other-R = 21). Fever and non-weight-bearing prior to admission were useful predictors of SA, though in C-SA patients, 21% did not have a fever and 23% could weight bear at the time of admission. Aspirate white blood cell (WBC) count was significantly greater in both C-SA (92 000 cells/hpf) and S-SA (54 000) than in Other (10 000) and Other-R (18 000) patients. The percentage of polymorphonuclear (%PMN) was also significantly greater in C-SA (81.1%) and S-SA (80.9%) than in Other (57.9%) and Other-R (63.3%). CONCLUSION: Joint aspirate values, especially %PMN, are valuable in diagnosing SA. Additionally, antibiotics pre-aspiration did not affect %PMN, facilitating subsequent diagnosis of infection. Lastly, while aspirate WBC count was a valuable indicator of SA, this finding is not as definitive as previous research suggests. LEVEL OF EVIDENCE: IV Case Series.

Impact of tranexamic acid use on blood loss and transfusion rates following femoral varus derotational osteotomy in children with cerebral palsy.

PURPOSE: Previous studies have established the safety and efficacy of tranexamic acid (TXA) in reducing blood loss after total joint arthroplasty and spinal fusion surgery; however, literature regarding the effectiveness of intraoperative TXA in children with cerebral palsy (CP) is limited. The aim of this study was to investigate the safety and efficacy of intraoperative TXA in reducing blood loss and transfusion requirements for children with CP undergoing a proximal femoral varus derotational osteotomy (VDRO). METHODS: This is a retrospective review of 258 children with CP who underwent VDRO performed at the author's institution between 2004 and 2017. In all, 36 subjects underwent VDRO surgery with administration of intravenous TXA and 222 subjects underwent VDRO without administration of TXA. Outcome measures including blood loss, transfusion requirements and venous thromboembolic events were compared between groups using t-tests and chi-squared tests. RESULTS: No significant differences were seen in the rates of transfusion between groups for the entire hospitalization (TXA group: 11.1% versus No TXA group: 19.8%), intraoperatively (TXA: 2.8% versus No TXA: 9.0%) or postoperatively (TXA: 8.3% versus No TXA: 14.4%). Intraoperative estimated blood loss (TXA: 144.4 mL versus No TXA: 159.0 mL) and percentage blood loss (TXA: 8.9% versus No TXA: 9.2%) were similar between groups. No major thromboembolic complications events occurred in either group. CONCLUSION: The use of TXA was not associated with thromboembolic complications in this series of children with CP undergoing VDRO surgery. Though there was a trend toward lower rates of intraoperative and postoperative blood transfusion with TXA use in these patients, the differences were not significant, possibly due to low estimated blood loss in both groups and sample size. LEVEL OF EVIDENCE: III- retrospective comparative study.

"Decide Now, Buy Marlboro": Examining the influence and appeal of Marlboro's new brand architecture among Filipino adolescents.

In recent years, Philip Morris International (PMI) launched a global rebranding strategy to expand the reach of Marlboro. Using a mixed-methods design, this study evaluated the appeal and influence of Marlboro advertising among Filipino youth. Six hundred and twenty-three adolescents aged 13-17 years old in Metro Manila participated in a survey, including three advertising conditions: two for Marlboro and one for Mighty, a local cigarette brand. One-way repeated measures analysis of variance (ANOVA) and paired t-tests evaluated differences between the three conditions on participants' attitudes toward advertisements [measured as identification, likeability, and perceived effectiveness (PE)]. Compared to Mighty, never-smokers rated Marlboro advertisements as more identifiable and likeable. Comparing by smoking status (never vs. ever), multivariable logistic regression assessed the influence of these attitudes on intention to smoke. Increased likeability was associated with greater intention to smoke among never-smokers, and greater PE increased odds of intention to smoke for both never- and ever-smokers. Additionally, six focus group discussions (FGD) explored responses to campaign messaging. Themes were compared within and across groups. Marlboro was also appealing to FGD participants, who described the ads as attractive to youth and promoting "adventure" and "freedom", whereas the Mighty brand was seen as being for adults and current smokers. Our findings illustrate that Marlboro advertisements are distinctly appealing to youth. Marlboro rhetoric - where consumers are urged to "decide" to "Be Marlboro" - was particularly powerful. These findings support the need for addressing gaps in policies regulating the marketing and promotion of tobacco in the Philippines.

Thermographic skin temperature measurement compared with cold sensation in predicting the efficacy and distribution of epidural anesthesia.

Due to the high rates of epidural failure (3-32%), novel techniques are required to objectively assess the successfulness of an epidural block. In this study we therefore investigated whether thermographic temperature measurements have a higher predictive value for a successful epidural block when compared to the cold sensation test as gold standard. Epidural anesthesia was induced in 61 patients undergoing elective abdominal, thoracic or orthopedic surgery. A thermographic picture was recorded at 5, 10 and 15 min following epidural anesthesia induction. After 15 min a cold sensation test was performed. Epidural anesthesia is associated with a decrease in skin temperature. Thermography predicts a successful epidural block with a sensitivity of 54% and a PPV of 92% and a specificity of 67% and a NPV of 17%. The cold sensation test shows a higher sensitivity and PPV than thermography (97 and 93%), but a lower specificity and NPV than thermography (25 and 50%). Thermographic temperature measurements can be used as an additional and objective method for the assessment of the effectiveness of an epidural block next to the cold sensation test, but have a low sensitivity and negative predictive value. The local decrease in temperature as observed in our study during epidural anesthesia is mainly attributed to a core-to-peripheral redistribution of body heat and vasodilation.

Quality of life improvement in older patients with heart failure initiated on ivabradine: Results from the UK multi-centre LIVE:LIFE prospective cohort study.

AIMS: LIVE:LIFE is a multi-centre, open-label, prospective observational cohort study assessing health-related quality of life (HRQoL) in older patients with chronic heart failure (CHF) following initiation of ivabradine. The primary endpoint is change in Minnesota Living with Heart Failure Questionnaire (MLWHFQ) total score after 6months. METHODS AND RESULTS: Consenting patients aged ≥70years with CHF, in whom ivabradine was initiated within its licensed indication, were enrolled. Demographic, clinical and HRQoL (MLWHFQ, SF-12) data were collected at baseline (V1), 2 (V2) and 6months (V3). Over 14months, 240 patients were recruited from 44 UK centres. Ninety-nine (41%) were female and 28% aged ≥80years. Aetiology was ischaemic in 152 (63%) and 59% had been diagnosed with CHF for ≤2yrs. 52% of patients were New York Heart Association (NYHA) Class III and 57% had left ventricular ejection fraction <35%. 57% received beta-blockers. Patients had multiple comorbidities (144 (60%) hypertension, 105 (44%) asthma/COPD, 80 (33%) diabetes) and were prescribed a mean of 9±3 daily medications. Resting heart rate was 83bpm at baseline and fell 13bpm by V3. In patients completing both visits (n=187), comparing V3 to baseline: MLWHFQ total score improved by 9 points (p<0.0001, 95% CI: 7-12); 30% of patients improved ≥1 NYHA class and global assessment improved from patient (59%) and physician (60%) perspectives. 88% of patients completing V3 were still taking ivabradine. CONCLUSIONS: These contemporary prospective UK data demonstrate improvements in HRQoL and functional status with ivabradine therapy in typical older CHF patients. Despite comorbidities and polypharmacy, ivabradine was well tolerated.

Liquid chromatography/mass spectrometry based detection and semi-quantitative analysis of INSL5 in human and murine tissues.

RATIONALE: Insulin-like peptide 5 (INSL5) is a hormone produced by enteroendocrine L-cells in the colon that has recently been implicated in the control of metabolic homeostasis. However, research into its physiology has been hindered by the reported unreliability of commercially available immunoassays and additional detection assays would benefit this emerging field. METHODS: Peptides from purified murine L-cells and homogenates from both human and mouse colonic tissues were extracted by precipitating larger proteins with acetonitrile. Untargeted liquid chromatography/tandem mass spectrometry (LC/MS/MS) analyses, followed by database searching, were used to detect and identify various INSL5 gene derived peptides and characterise their precise sequence. A similar approach was developed to quantify INSL5 levels in primary intestinal culture supernatants after purification and concentration by solid-phase extraction. RESULTS: Mass spectral analysis of purified enteroendocrine cells and tissue homogenates identified the exact sequence of A and B chains of INSL5 endogenously expressed in L-cells. Differences in the endogenously processed peptide and the Swissprot database entry were observed for murine INSL5, whereas the human sequence matched previous predictions from heterologous expression experiments. INSL5 was detected in the supernatant of human and mouse primary colonic cultures and concentrations increased after treatment with a known L-cell stimulus. CONCLUSIONS: The first LC/MS/MS-based method capable of the detection and semi-quantitative analysis of endogenous INSL5 using MS-based techniques has been demonstrated. The methodology will enable the identification of stimulants for INSL5 secretion from murine and human primary colonic epithelial cultures.

Dynamically controlled deposition of colloidal nanoparticle suspension in evaporating drops using laser radiation.

Dynamic control of the distribution of polystyrene suspended nanoparticles in evaporating droplets is investigated using a 2.9 µm high power laser. Under laser radiation a droplet is locally heated and fluid flows are induced that overcome the capillary flow, and thus a reversal of the coffee-stain effect is observed. Suspension particles are accumulated in a localised area, one order of magnitude smaller than the original droplet size. By scanning the laser beam over the droplet, particles can be deposited in an arbitrary pattern. This finding raises the possibility for direct laser writing of suspended particles through a liquid layer. Furthermore, a highly uniform coating is possible by manipulating the laser beam diameter and exposure time. The effect is expected to be universally applicable to aqueous solutions independent of solutes (either particles or molecules) and deposited substrates.

Clinical utility of C-terminal telopeptide of type 1 collagen in multiple myeloma.

Myeloma bone disease (MBD) is a major cause of morbidity in multiple myeloma (MM). We investigated bone turnover markers (BTM) as relapse predictors and biomarkers for monitoring MBD. We measured C-terminal telopeptide of type I collagen (CTX-1), and Procollagen type 1 N Propeptide (P1NP) in 86 MM patients and 26 controls. CTX-1 was higher in newly diagnosed patients compared to control, remission and relapse (P < 0·05), and decreased following treatment. In the setting of relapse, a CTX-1 rise greater than the calculated least significant change (LSC) was observed in 26% of patients 3-6 months prior to relapse (P = 0·007), and in 60·8% up to 3 months before relapse (P = 0·015). Statistically significant changes in CTX-1 levels were also observed in patients who were with and without bisphosphonate therapy at the time of relapse. In patients with normal renal function, mean CTX-1 level was highest in the newly diagnosed group (0·771 ± 0·400 µg/l), and lowest in the remission group (0·099 ± 0·070 µg/l) (P < 0·0001). P1NP levels were not statistically different across the patient groups. We conclude that CTX-1, measured on an automated hospital laboratory platform, has a role in routine treatment monitoring and predicting relapse of MBD, even in patients on bisphosphonates.

The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations.

BACKGROUND: Do-not-resuscitate (DNR) orders allow patients to communicate their wishes regarding cardiopulmonary resuscitation. Although DNR status may influence physician decision making regarding resuscitation, the effect of DNR status on outcomes of patients undergoing emergency vascular operation remains unknown. The aim of this study was to analyze the effect of DNR status on the outcomes of emergency vascular surgery. METHODS: The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency vascular surgical interventions between 2005 and 2010. Demographics, clinical data, and outcomes were extracted. Patients were compared according to DNR status. The primary outcome measure was 30-day mortality. RESULTS: During the study period, 16,678 patients underwent emergency vascular operations (10.8% of the total vascular surgery population). Of those, 548 patients (3.3%) had a DNR status. The differences in rates of open or endovascular repair or of intraoperative blood requirement between the two groups were not significant. After adjusting for differences in demographics and clinical data, DNR patients were more likely to have higher rates of graft failure (8.7% vs 2.4%; adjusted P < .01) and failure to wean from mechanical ventilation (14.9 % vs 9.9%; adjusted P < .001). DNR status was associated with a 2.5-fold rise in 30-day mortality (35.0% vs 14.0%; 95% confidence interval, 1.7-2.9; adjusted P < .001). CONCLUSIONS: The presence of a DNR order was independently associated with mortality. Patient and family counseling on surgical expectations before emergency vascular operations is warranted because the risks of perioperative events are significantly elevated when a DNR order exists.

Outcomes of endovascular management of acute thoracic aortic emergencies in an academic level 1 trauma center.

BACKGROUND: Thoracic aortic emergencies account for 10% of thoracic-related admissions in the United States and remain associated with high morbidity and mortality rates. Open repair has declined owing to the emergence of thoracic endovascular aortic repair (TEVAR), but data on emergency TEVAR use for acute aortic pathology remain limited. We therefore reviewed our experience. METHODS: We retrospectively evaluated emergency descending thoracic aortic endovascular interventions performed at a single academic level 1 trauma center between January 2005 and August 2013 including all cases of traumatic aortic injury, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, aortoenteric fistula, and acute complicated type B dissection. Demographics, clinical data, and outcomes were extracted. Stepwise logistic regression was used to identify independent risk factors for death. RESULTS: During the study period, 51 patients underwent TEVAR; 22 cases (43.1%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n = 16) were male with a mean age of 54.8 ± 15.9 years. Nineteen patients (86.4%) required only a single TEVAR procedure, whereas 2 (9.1%) required additional endovascular therapy, and 1 (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital length of stay of 18.9 days (range, 1 to 76 days), 3 patients (13.6%) developed major complications. In-hospital mortality was 27.2%, consisting of 6 deaths from traumatic brain injury (1); exsanguination in the operating room before repair could be achieved (2); bowel ischemia (1) and multisystem organ failure (1); and family withdrawal of care (1). A stepwise logistic regression model identified 24-hour packed red blood cell requirements ≥4 units, admission mean arterial pressure <60 mm Hg, and 24-hour fresh frozen plasma to packed red blood cell (pRBC) ratio <1:1.5 as independent risk factors for death in this cohort. During a mean follow-up of 369 days (range, 35 to 957 days), no subsequent major complications or deaths occurred. All patients underwent serial computed tomographic angiography surveillance, and no device-related problems were identified during intermediate follow-up. CONCLUSIONS: Thoracic aortic emergencies remain challenging. Our experience in a moderate-volume center supports the utilization of TEVAR in the acute setting. Twenty-four-hour pRBC requirements ≥4 units, admission mean arterial pressure <60 mm Hg, and 24 hour fresh frozen plasma to pRBC ratio <1:1.5 were independently associated with death.

Trends and outcomes of endovascular therapy in the management of civilian vascular injuries.

OBJECTIVE: The rapid evolution of endovascular surgery has greatly expanded management options for a wide variety of vascular diseases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries. METHODS: A 9-year analysis of the National Trauma Data Bank was performed to identify all patients who sustained arterial injuries. Demographics, clinical data, interventions, and outcomes were extracted. Propensity scores were used to match endovascular patients to those undergoing open operation. Patient outcomes were compared according to treatment approach. RESULTS: A total of 23,105 patients were available for analysis. Overall, there was a significant increase in the use of endovascular procedures during 9 years (from 0.3% in 2002 to 9.0% in 2010; P < .001), particularly among blunt trauma patients (from 0.4% in 2002 to 13.2% in 2010; P < .001). This increase was noteworthy and dramatic for injuries of the internal iliac artery (from 8.0% in 2002 to 40.3% in 2010; P < .001), thoracic aorta (from 0.5% in 2002 to 21.9% in 2010; P < .001), and common/external iliac arteries (from 0.4% in 2002 to 20.4% in 2010; P < .001). A significant decrease was noted for open procedures (49.1% in 2002 to 45.6%; P < .001), especially for blunt trauma (42.9% in 2002 to 35.8% in 2010; P < .001). There was a stepwise increase in the proportion of patients managed by endovascular therapy as the Injury Severity Score increased (highest in the spectrum Injury Severity Score 31-50). When outcomes were compared between matched patients who underwent endovascular and open procedures, patients who underwent endovascular procedures had significantly lower in-hospital mortality (12.9% vs 22.4%; odds ratio, 0.5; 95% confidence interval, 0.4-0.6; P < .001). Endovascular patients also had decreased rates of sepsis (7.5% vs 5.4%; odds ratio, 0.7; 95% confidence interval, 0.5-0.9; P = .025). CONCLUSIONS: The use of endovascular therapy in the United States has increased dramatically during the last decade, in particular among severely injured blunt trauma patients. Endovascular therapy was associated with improved in-hospital mortality and lower rates of sepsis.

Delaying treatment of supracondylar fractures in children: has the pendulum swung too far?

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

Complete division of the radial nerve associated with a closed fracture of the humeral shaft in a child.

The management of closed fractures of the humerus with an associated nerve palsy remains controversial. With very little written about this injury in children, we present the case of a three-year-old child with a closed humeral shaft fracture in whom surgical exploration and reconstruction of the radial nerve with a sural nerve graft was performed three months after injury. The child regained full function. To the best of our knowledge, this is the first such case to be reported in the English literature.

Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture.

BACKGROUND: There is an uncommon subset of supracondylar humeral fractures in children that are so unstable they can displace into both flexion and extension. The purposes of this study were to describe this subset of supracondylar fractures and to report a new technique of closed reduction and percutaneous pinning for their treatment. METHODS: In a retrospective review of 297 consecutive displaced supracondylar humeral fractures in children treated operatively at our institution, we identified nine that were completely unstable with documented displacement into both flexion and extension as seen on fluoroscopic examination with the patient under anesthesia. We used a new technique for closed reduction and fixation of these fractures, and then we assessed fracture-healing and complications from the injury and treatment. RESULTS: All nine fractures were treated satisfactorily with closed reduction and percutaneous pinning. The complication rate associated with these unstable fractures was no higher than that associated with the 288 more stable fractures. Seven of the nine fractures were stabilized with lateral entry pin placement, and two fractures were stabilized with crossed medial and lateral pins. None of the patients had a nonunion, cubitus varus, malunion, additional surgery, or loss of motion. CONCLUSIONS: In rare supracondylar fractures in children, multidirectional instability results in displacement into flexion and/or extension. This fracture can be classified as type IV according to the Gartland system, as it is less stable than a Gartland type-III extension supracondylar fracture. These fractures can be treated successfully with a new technique of closed reduction and percutaneous pinning, thus avoiding open reduction.