Serial ultrasound evaluation of pediatric trigger thumb.

BACKGROUND: The etiology of pediatric trigger thumb is unknown, although ultrasound in adults has shown thickening of the A1 pulley leading to constriction of the flexor pollicis longus (FPL) tendon. The purpose of this study is to characterize the underlying cause of the pediatric trigger thumb and factors responsible for resolution utilizing sonography. METHODS: A prospective analysis of children with trigger thumbs was conducted from May 2008 through June 2010. All children were initially treated with splinting. Surgical release of the A1 pulley was performed at the family's request. Bilateral dynamic ultrasonography was performed at presentation and follow-up until resolution of triggering. Ultrasound images were evaluated for tendon gliding, echotexture, cross-sectional area, and anatomic variations. RESULTS: There were 35 trigger thumbs in 28 patients. Ten thumbs resolved spontaneously. Eight patients (9 thumbs) underwent surgical release of the A1 pulley. One child who underwent bilateral release achieved only unilateral resolution. Ultrasound imaging of all 56 thumbs demonstrated normal echotexture of the FPL without evidence of inflammation or trauma. Triggering always occurred at the A1 pulley, and there was focal enlargement of the FPL but no definite ultrasound abnormality of the A1 pulley. Surgical release allowed the thickened tendon to pass smoothly, which coincided with resolution of triggering. Two of 3 patients with unilateral triggering presenting with a trigger ratio (cross-sectional area of involved maxFPL to uninvolved FPL) <1.5 converted to bilateral trigger thumbs. An FPL size for age graph was created for nontriggering thumbs in unilateral patients. CONCLUSIONS: The pediatric trigger thumb is a developmental condition with normal echotexture noted in all FPL tendons without inflammation or trauma. Triggering occurs when the cross-sectional area of the FPL exceeds the cross-sectional area at the A1 pulley, and it resolves when this size disparity is eliminated. Patients with unilateral triggering and a trigger ratio <1.5 on the uninvolved thumb are at risk for developing triggering bilaterally. LEVEL OF EVIDENCE: Level 2 diagnostic study.

Fibular Hypoplasia, Talar Aplasia, Absent Proximal Tibial Growth Plate and Oligosyndactyly (Variant of Fibular Aplasia, Tibial Campomelia, and Oligosyndactyly Syndrome) - Paucity of Case Reports with Evolving Definition.

INTRODUCTION: Fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO) syndrome is a rare disorder with unknown molecular basis. Since it is a rare disorder, so it is commendable to report the each case, due to its sporadic incidence and paucity of the standardized management protocol for their management. CASE REPORT: It is a case report of newly born male baby, whose anxious parents presented to the outpatient department with a deformity in the left lower limb. This resembled the FATCO syndrome. After clinico-radiological workup, it was categorized as a variant of FATCO syndrome. CONCLUSION: Counseling of parents should be done and let them realize that what is inescapable with this syndrome and what is bound to happen during the treatment.

Anterior Bridge Plate Osteosynthesis in Comminuted Fracture Shaft of Humerus in Manual Workers- is it Optimum Choice?

BACKGROUND: Bridge plate osteosynthesis of fractures by minimal invasion and near acceptable reduction is becoming popular and acceptable entity. Management of humeral shaft fracture has evolved a lot with their pros and cons. Anterior bridge plate osteosynthesis (ABPO) for humeral shaft fracture is pertinent to a minimal invasive procedure, and it has evolved as a new entrant in the surgical techniques. This study was designed to carry out the results and efficacy of ABPO in the comminuted fracture shaft of the humerus in the manual workers. METHODS: Study included the closed comminuted fracture of shaft of humerus in skeletally mature patients engaged predominantly in manual works, like overhead sports activity, laborers, and industrial workers. All fractures were managed by either 4.5-mm narrow locking compression plate (LCP) or dynamic compression plate (DCP).The functional outcome for elbow was measured by Mayo's elbow performance score (MEPS) and functional outcome of shoulder was measured by UCLA (University of California at Los Angeles) shoulder score system. RESULTS: In this study 37 patients were enrolled. Mean duration for satisfactory radiographic union was 12.3 weeks. The mean duration of follow-up period was 14.5 months. In respect to elbow function, the average Mayo elbow score was 92.42 ±2.17 and average UCLA score of shoulder function was 34 ±0.34. CONCLUSION: The ABPO is an optimum choice for managing the comminuted fracture shaft of humerus in manual labors. The outcomes are favorable and reproducible with very few risks.

Intrathoracic fluid extravasation after hip arthroscopy.

The case of intrathoracic extravasation of irrigation fluid after hip arthroscopy in a 21-year-old woman is presented. In this patient intraperitoneal and retroperitoneal fluid collection developed, as seen in other case reports documenting irrigation fluid extravasation during hip arthroscopy. The patient presented to the emergency department on the first postoperative day complaining of shortness of breath. Computed tomography of the chest, abdomen, and pelvis showed retroperitoneal fluid, extensive abdominal ascites, and bilateral pleural effusions within the chest. The fluid diminished pulmonary volume by elevating the diaphragm and causing compression atelectasis of both lungs. The patient's hemodynamic status was stable and unaffected. She developed hypothermia during the procedure, which is consistent with other reports on extravasated irrigation fluid during arthroscopy. She was able to rapidly compensate for fluid overload and eliminated it uneventfully, with resolution of her symptoms. A similar procedure was performed on the contralateral hip 6 months later. During that procedure, there was a suspected (not confirmed) recurrence of intraperitoneal extravasation of the pump fluid as well as transient hypothermia, which resolved by the first postoperative visit. The physiologic effects of intrathoracic fluid accumulation and the literature regarding extravasation of irrigation fluid during hip arthroscopy are also reviewed.

Community-associated methicillin-resistant Staphylococcus aureus in acute musculoskeletal infection in children: a game changer.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a virulent pathogen responsible for an increasing number of invasive musculoskeletal infections in healthy children. The purpose of this study is to characterize the presentation, clinical course, treatment, complications, and long-term morbidity of CA-MRSA musculoskeletal infection in children. METHODS: A retrospective study of children with CA-MRSA musculoskeletal infections from 2 institutions was conducted. RESULTS: The study group included 27 patients. Clinical presentation involved an extremity in 23 of 27 patients. Twelve patients required admission to the intensive care unit. Four of these patients developed acute multisystem failure. Magnetic resonance imaging was obtained in 21 patients and was diagnostic in all. Seven patients developed deep venous thrombosis and septic pulmonary emboli. All patients required surgical intervention, and 16 of 27 required multiple debridements. CONCLUSIONS: CA-MRSA is limb and life threatening. Prompt recognition and treatment are critical. Aggressive surgical drainage/debridement in addition to long-term antibiotics is required. There is significant potential for long-term morbidity despite aggressive management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The Ioban drape: a simple method to improve finger surgery safety and efficiency.

Surgery involving the fingers can be technically challenging especially when utilizing fluoroscopic imaging. The surgical field is often obscured by the remaining fingers and attempts to position the hand may expose the surgeon and assistants to additional radiation exposure. This paper describes a simple and effective technique to remove the uninvolved fingers from the surgical field allowing for a more efficient operative procedure with less radiation exposure.