Complications of pediatric elbow dislocations and monteggia fracture-dislocations.

Pediatric elbow dislocations and Monteggia lesions are prone to acute and chronic complications. A pediatric patient's cartilaginous and unossified distal humerus contributes to the risks of inaccurate diagnoses resulting from the misinterpretation of findings on plain radiographs. The debate continues regarding the amount of acceptable displacement for medial epicondyle fractures. In contrast, the radial head should always point directly to the capitellum. Chronic complications include instability and arthritis. Instability, which can be subtle and difficult to diagnose, can occur in the medial or the posterolateral direction, depending on the injured stabilizer. Restoration of stability remains the mainstay of treatment. Pediatric traumatic arthritis is extremely difficult to manage with surgery because of the limited number of reliable treatment options.

Complications of pediatric distal radius and forearm fractures.

Distal radius and forearm fractures represent a large percentage of pediatric fractures. The most common mechanism of injury is a fall onto an outstretched arm, which can lead to substantial rotational displacement. If this rotational displacement is not adequately addressed, there will be resultant loss of forearm motion and subsequent limitations in performing the activities of daily living. Good initial reductions and proper casting techniques are necessary when treating distal radius and forearm fractures nonsurgically; however, maintaining an acceptable reduction is not always possible. Atraumatic reduction of a displaced physeal fracture should occur within 7 days of the injury. If an impending malunion presents at 2 weeks or later after injury, observation is warranted because of concerns about physeal arrest with repeated attempts at manipulation, and it should be followed by a later assessment of functional limitations. Pediatric patients and their parents have higher expectations for recovery, which has contributed to an increase in the surgical management of pediatric distal radius and forearm fractures. In addition, surgical interventions, such as intramedullary nailing, have their own associated complications.

Complications of pediatric femoral shaft and distal physeal fractures.

Fractures of the femoral shaft comprise about 1.6% of all bony injuries in children and are the most common pediatric orthopaedic injury that requires hospitalization. The treatment of femoral fractures in children is largely dependent on the child's age and size and takes into account multiple considerations: the child's weight, associated injuries, the fracture pattern, the mechanism of injury, institutional or surgeons' preferences, and economic and social concerns. In addition, during the past two decades, there has been a dramatic change favoring surgical fixation rather than casting because of the many advantages of fixation, including more rapid mobilization. The goal of treatment should be to ultimately obtain a healed fracture and avoid associated complications, such as nonunion or delayed union, angular or rotational deformity, unequal limb lengths, infection, neurovascular injury, disruption of the growth plate, muscle weakness, and/or compartment syndrome.

Complications of pediatric supracondylar humeral fractures.

Supracondylar humeral fractures are common in the pediatric population and can result in complications caused by both the injury itself and surgical or nonsurgical treatment. Neurologic complications are frequent, with the anterior interosseous nerve being the most common nerve affected. Vascular injuries, although less common, can result in long-term sequelae and should be recognized and treated promptly. Loss of reduction can occur with both surgical and nonsurgical treatment. Compartment syndrome and infection, although rare, require rapid recognition and treatment. It is important to be familiar with the potential complications surrounding the treatment of pediatric supracondylar humeral fractures to maximize outcomes and know when a referral may be warranted.

A Novel Prevention Bundle to Reduce Surgical Site Infections in Pediatric Spinal Fusion Patients.

BACKGROUND: The Surgical Care Improvement Project bundle emphasizes operative infection prevention practices. Despite implementing the Surgical Care Improvement Project bundle in 2008, spinal fusion surgical site infections (SF-SSI) continued to be prevalent for this low-volume, high-risk surgery. OBJECTIVE: To design a combined pre-, peri-, and postoperative bundle (PPPB) that would lead to sustained reductions in SF-SSI rates. DESIGN: Quality improvement project, before-after trial with cost-effectiveness analysis. SETTING: Children's hospital. PATIENTS: All spinal fusion patients, 2008-2015. INTERVENTION: A multidisciplinary team developed the PPPB composed of Surgical Care Improvement Project elements plus improved wound care practices, nursing standard of care, dedicated nursing unit, dermatology assessment tool and consultation, nursing education tool using "teach back" technique, and a "Back Home" kit. SF-SSI rates were compared before (2008-2010) and after (2011-February 2015) implementation of PPPB. PPPB compliance was monitored. RESULTS: A total of 224 SF surgeries were performed from 2008 to February 2015. Pre-PPPB analysis revealed median time to SF-SSI of 28 days, secondary to skin and bowel flora. Mean 3-year pre-PPPB SF-SSI rate per 100 SF surgeries was 8.2 (8/98) (2008: 13.3 [4/30], 2009: 2.7 [1/37], 2010: 9.7 [3/31]). Mean SF-SSI rate after PPPB was 2.4 (3/126) (January 2011-February 2015); there was a 71% reduction in mean SSI rate (P=.0695). No SF-SSI occurred in neuromuscular patients (P=.008) after PPPB. Compliance with PPPB elements has been 100%. CONCLUSIONS: PPPB led to sustained improvement in SF-SSI rates over 50 months. The PPPB could be reproduced for other surgeries.