Kirschner wire infections in pediatric orthopaedic surgery.

BACKGROUND: Few studies have described the presentation, bacteriology, risk factors, and complications of Kirschner wire infections in pediatrics. The purpose of this study is to describe these factors to better understand, prevent, and treat infectious complications of smooth wires. METHODS: A retrospective review was performed to identify all patients (birth to 16 y) who were hospitalized for Kirschner wire infection from 1995 to 2012. Presentation, hospital course, bacteriology, outcomes, and complications were recorded. A management algorithm was developed from the experience. RESULTS: Kirschner wire infections were present in 12 patients: 5 supracondylar fractures, 3 lateral humeral condylar fractures, a distal tibia physeal fracture, a great toe open fracture, a distal radius fracture, and an elective osteotomy for hallux valgus. The patients presented with cellulitis in 3 cases, soft-tissue abscess in 4 cases, osteomyelitis in 4 cases, and 1 case of toxic shock syndrome. A history of missed appointments or wet dressing was present in 60% of cases. Reoperation was required in 5 patients with abscess, septic arthritis, or osteomyelitis. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen followed by Pseudomonas aeruginosa. Methicillin-resistant S. aureus was not seen. Complications were present in 5 patients and included: loss of range of motion, joint destruction, wound breakdown, catheter migration, and toxic shock syndrome. CONCLUSIONS: Infected Kirschner wires are rare and may be maintained in a nonunited bone if the infection is superficial. Infections in this series commonly had a history of missed appointments and wet dressings, which suggests that improved postoperative education may reduce the risk. Osteomyelitis was often preceded by pin-site drainage and failed oral antibiotic therapy. MSSA and Pseudomonas were most commonly cultured and should be considered when empiric antibiotic therapy is necessary. LEVEL OF EVIDENCE: Prognostic level IV.

Incidence and etiology of unplanned cast changes for fractures in the pediatric population.

BACKGROUND: The majority of pediatric fractures are treated in casts due to the child's ability to heal rapidly and remodel. Unplanned cast changes are a time and economic burden with potentially adverse effects on fracture management. The purpose of this study is to document the incidence, etiology, and complications related to unplanned cast changes. METHODS: A prospective study was conducted over a 6-month period to determine the incidence of unplanned cast changes. All casts applied were nonwaterproof. Data collected include the reason for cast placement, type of cast placed, duration of wear before the unplanned change, reason for the unplanned change, experience level of the original cast applicator, and cast-related complications. RESULTS: A total of 1135 casts were placed with 58% placed by a resident, 38% by a cast technician, 2% by a physician's assistant, and 2% by an attending physician. Sixty casts (5.3%) required an unplanned change including 19 short-arm casts, 18 short-leg casts, 17 long-arm casts, 4 thumb spica casts, and 2 long-leg casts. The average duration from cast application until the unplanned change was 13 days. Twenty-eight (47%) were changed for wetness, 20 (33%) for wear/breakage, 2 (3%) for skin irritation, and 10 (17%) for other reasons including objects in the cast and patient self-removal. Two patients had superficial skin infections requiring oral antibiotics. No fracture reductions were lost secondary to an unplanned cast change. The need for an unplanned cast change did not correlate with the level of experience of the applicator. CONCLUSIONS: Most unplanned cast changes were the result of patient nonadherence to instructions and not related to cast application technique. Improved patient and family education regarding cast care may reduce the frequency of unplanned cast changes, thus reducing an economic and time burden on the health care system. LEVEL OF EVIDENCE: Level II--prognostic study.

Postoperative pain control after supracondylar humerus fracture fixation.

BACKGROUND: Postoperative pain control in pediatric patients has become a priority for all institutions. There is a paucity of literature on pain control after orthopedic procedures in the pediatric population. The purpose of this study is to compare the efficacy of acetaminophen with narcotic analgesics, specifically, acetaminophen/codeine and morphine, for pain management after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children. METHODS: We retrospectively evaluated 217 patients who received closed reduction and percutaneous pinning of type II or III supracondylar humerus fractures at our institution from 2003 to 2009. Hospital charts were reviewed to obtain demographic data. Patients were divided into narcotic and non-narcotic groups. The Oucher and FLACC scales were used to quantify the effectiveness of the pain control that was delivered. RESULTS: A total of 174 patients were treated with non-narcotic pain medications and 43 patients received narcotics. The average age of these patients was 5.45 years. The mean postoperative pain score for the non-narcotic group was 1.9, whereas the mean postoperative pain score for the narcotic group was 2.2. This difference was not statistically significant. To account for the difference of age in patients and severity of fracture type, we created an age-matched cohort of patients with only type III supracondylar fractures. The average age of this group was 6.22 years. The mean pain score for the acetaminophen subgroup was 2.1 compared with a mean pain score of 2.4 for the narcotic subgroup. This difference was not statistically significant. Severe nausea or vomiting attributed to either class of medication was not observed. In addition, no patients developed a compartment syndrome. CONCLUSIONS: Acetaminophen is as effective as narcotic analgesics for providing pain control after supracondylar fracture surgery in children and is historically associated with fewer side effects. It is our recommendation to use acetaminophen alone for postoperative pain control in these patients. LEVEL OF EVIDENCE: III.

Top 10 pediatric orthopaedic surgical emergencies: a case-based approach for the surgeon on call.

Pediatric patients who require orthopaedic surgical emergency care are often treated by orthopaedic surgeons who primarily treat adult patients. Essential information is needed to safely evaluate and treat the most common surgical emergencies in pediatric patients, including hip fractures; supracondylar humeral, femoral, and tibial conditions of the hip (such as slipped capital femoral epiphysis and septic arthritis); and limb- and life-threatening pathologies, including compartment syndrome, the dysvascular limb, cervical spine trauma, and the polytraumatized child. To provide optimal care to pediatric patients, it is important to be aware of the key points in patient evaluation and surgical care as well as expected complications.

Hip fractures in children.

Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.

Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management.

Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (< or =50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw-laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.

Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management.

Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.

Injury of the cervical spine in young children.

The evaluation of injury of the cervical spine in children is complicated by biomechanics of the pediatric cervical spine that differ from those in the adult, by incomplete maturation and ossification of the vertebral segments, and by difficulties the physician may have in communicating with the child. Because the upper cervical region, from occiput to C2, is most susceptible to injury in children, it is important to have an understanding of mechanisms of injury, diagnostic imaging modalities, and therapeutic interventions. A clear understanding of adult and pediatric cervical spine differences will facilitate early diagnosis and appropriate treatment of cervical spine injuries in young children.

Infections and inflammatory conditions of the cervical spine in children.

Because infections and inflammatory disorders of the cervical spine are uncommon in children and adolescents, diagnosis and treatment are frequently delayed. Intractable pain, limitation of neck motion, and neurologic compromise may occur as the result of these pathologic processes. It is important to identify these symptoms for early diagnosis and treatment of conditions such as bacterial and tuberculous infections, intervertebral disk calcification, juvenile rheumatoid arthritis, and Grisel's syndrome.

Tibial shaft fractures in children and adolescents.

Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.

Musculoskeletal infections in children: basic treatment principles and recent advancements.

Pediatric musculoskeletal infections are common disorders that can result in significant disability. Because the understanding, diagnosis, and treatment of infections of the bones, joints, and soft tissues have continued to improve over time, it is important for orthopaedic surgeons to have an understanding of the etiology, diagnosis, basic treatment principles, and recent advancements to achieve successful outcomes. Although each infectious process is unique, there are certain treatment principles that apply to all pediatric musculoskeletal infections. These include prevention, a prompt and accurate diagnosis, and timely medical and/or surgical intervention. Continued evaluations are mandatory to assure good long-term outcomes. Because the effects of infection may last beyond the acute episode in pediatric patients, long-term follow-up is needed to assess for late sequelae such as angular deformities and limb-length inequalities.

Spondylolysis and spondylolisthesis in the child and adolescent athlete.

Spondylolysis and spondylolisthesis are common causes of low back pain in the competitive athlete. Repetitive loading of the lumbar spine results in stress reactions and spondylytic defects of the pars interarticularis. Spondylolysis and lesser degrees of spondylolisthesis frequently respond to activity restrictions, bracing (in specific situations), and physiotherapy. Spinal fusion is indicated for spondylolysis and spondylolisthesis that remain painful despite nonoperative measures and progressive, high-grade spondylolisthesis. Return-to-play guidelines are made for each athlete individually based on his or her specific diagnosis, response to treatment, and sporting activity.

Nonsurgical treatment of kyphosis.

An increase in thoracic kyphosis in children and adolescents is usually the result of postural kyphosis or Scheuermann's kyphosis. Although no structural deformity of the spine is observed in postural kyphosis, wedging of vertebral bodies and disk space narrowing are noted radiographically in patients with Scheuermann's kyphosis. Effective interventions for adolescents with postural kyphosis include exercises to relieve lower extremity contractures and strengthen abdominal musculature coupled with practiced normal posture in stance and in sitting. Skeletally immature patients with Scheuermann's kyphosis benefit from a similar exercise program but also require the use of a spinal orthosis. Bracing of the spine in patients with Scheuermann's kyphosis results in permanent correction of vertebral deformity, unlike bracing in patients with idiopathic scoliosis. The evaluation of children and adolescents with increased thoracic kyphosis is an important aspect of the decision process used to determine appropriate interventions.

ACR Appropriateness Criteria(®) on suspected physical abuse-child.

The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria(®) Expert Panel on Pediatric Imaging.

Neurophysiological detection of impending spinal cord injury during scoliosis surgery.

BACKGROUND: Despite the many reports attesting to the efficacy of intraoperative somatosensory evoked potential monitoring in reducing the prevalence of iatrogenic spinal cord injury during corrective scoliosis surgery, these afferent neurophysiological signals can provide only indirect evidence of injury to the motor tracts since they monitor posterior column function. Early reports on the use of transcranial electric motor evoked potentials to monitor the corticospinal motor tracts directly suggested that the method holds great promise for improving detection of emerging spinal cord injury. We sought to compare the efficacy of these two methods of monitoring to detect impending iatrogenic neural injury during scoliosis surgery. METHODS: We reviewed the intraoperative neurophysiological monitoring records of 1121 consecutive patients (834 female and 287 male) with adolescent idiopathic scoliosis (mean age, 13.9 years) treated between 2000 and 2004 at four pediatric spine centers. The same group of experienced surgical neurophysiologists monitored spinal cord function in all patients with use of a standardized multimodality technique with the patient under total intravenous anesthesia. A relevant neurophysiological change (an alert) was defined as a reduction in amplitude (unilateral or bilateral) of at least 50% for somatosensory evoked potentials and at least 65% for transcranial electric motor evoked potentials compared with baseline. RESULTS: Thirty-eight (3.4%) of the 1121 patients had recordings that met the criteria for a relevant signal change (i.e., an alert). Of those thirty-eight patients, seventeen showed suppression of the amplitude of transcranial electric motor evoked potentials in excess of 65% without any evidence of changes in somatosensory evoked potentials. In nine of the thirty-eight patients, the signal change was related to hypotension and was corrected with augmentation of the blood pressure. The remaining twenty-nine patients had an alert that was related directly to a surgical maneuver. Three alerts occurred following segmental vessel clamping, and the remaining twenty-six were related to posterior instrumentation and correction. Nine (35%) of these twenty-six patients with an instrumentation-related alert, or 0.8% of the cohort, awoke with a transient motor and/or sensory deficit. Seven of these nine patients presented solely with a motor deficit, which was detected by intraoperative monitoring of transcranial electric motor evoked potentials in all cases, and two patients had only sensory symptoms. Somatosensory evoked potential monitoring failed to identify a motor deficit in four of the seven patients with a confirmed motor deficit. Furthermore, when changes in somatosensory evoked potentials occurred, they lagged behind the changes in transcranial electric motor evoked potentials by an average of approximately five minutes. With an appropriate response to the alert, the motor or sensory deficit resolved in all nine patients within one to ninety days. CONCLUSIONS: This study underscores the advantage of monitoring the spinal cord motor tracts directly by recording transcranial electric motor evoked potentials in addition to somatosensory evoked potentials. Transcranial electric motor evoked potentials are exquisitely sensitive to altered spinal cord blood flow due to either hypotension or a vascular insult. Moreover, changes in transcranial electric motor evoked potentials are detected earlier than are changes in somatosensory evoked potentials, thereby facilitating more rapid identification of impending spinal cord injury.

Prader-Willi Syndrome: clinical concerns for the orthopaedic surgeon.

BACKGROUND: Prader-Willi Syndrome (PWS) is a chromosome 15 disorder characterized by hypotonia, hypogonadism, hyperphagia, and obesity. Musculoskeletal manifestations, including scoliosis, hip dysplasia, and lower limb alignment abnormalities, are well described in the orthopaedic literature. However, care of this patient population from the orthopaedic surgeon's perspective is complicated by other clinical manifestations of PWS. Osteopenia, psychiatric disorders, and diminished pain sensitivity are frequently noted in PWS but are not discussed in the orthopaedic literature. The authors present a clinical review of an 8-year experience of caring for 31 patients with PWS to highlight all clinical concerns that influence orthopaedic management. METHODS: Thirty-one institutionalized patients diagnosed with PWS were examined and all past medical records were reviewed. Patient demographics, genetic testing, musculoskeletal diagnoses, psychiatric diagnoses, and clinical behaviors were recorded. Radiological studies performed in the course of routine clinical care were evaluated. RESULTS: Twenty-three men and 8 women, with an average age of 22 years (range, 8-39 years), were studied. A chromosome 15q abnormality was confirmed in 18 patients. Scoliosis was clinically detected in 21 of 30 patients and confirmed by radiographs in 14 of these 24 patients (overall with scoliosis, 45%) with an average primary curve of 27 degrees; 3 were braced, and 2 underwent spinal fusion. Radiographs also revealed diminished cervical lordosis and increased cervicothoracic kyphosis in 16 patients, a previously undescribed finding. Hip radiographs of 26 patients revealed dysplasia in 2 patients (13%); no slipped capital femoral epiphysis were identified. Fourteen patients had sustained a total of 58 fractures, with 6 patients sustaining multiple fractures (range, 2-7). Six patients have undergone orthopaedic surgical procedures with one major complication (spinal infection). Fracture management was associated with frequent minor complications. Bone densitometry was performed on 14 patients; 8 patients had osteopenia, and 4 had osteoporosis based on lumbar spine z scores. Twenty-six patients had Axis I psychiatric diagnoses including impulse control disorder (7), organic personality disorder (6), oppositional defiant disorder (5), dysthymic disorder (4), depressive disorder not otherwise specified (3), attention-deficit/hyperactivity disorder (2), and obsessive-compulsive disorder (2). Nine patients exhibited self-mutilating behaviors. CONCLUSIONS: Osteopenia, poor impulse control and defiant behaviors, and diminished pain sensitivity are aspects of PWS that may complicate all facets of orthopaedic nonsurgical and surgical management in this patient population. The treating orthopaedic surgeon must plan carefully and proceed with caution when treating children and adults with PWS.

Spondylolysis and spondylolisthesis in the child and adolescent: a new classification.

Spondylolysis and spondylolisthesis commonly are diagnosed in children and adolescents. The diagnostic workup and treatment plan vary widely among physicians. Although the orthopaedic literature is extensive on the topic, it is our opinion that a lack of clarity exists with regards to etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment. Important basic principles regarding spondylolysis and spondylolisthesis, with emphasis on clinical evaluation and nonsurgical treatment, serve as the basis for a new classification. We propose a new classification for pediatric spondylolysis and spondylolisthesis that is comprehensive, simple, and easily applied. This scheme is based on clinical presentation and spinal morphology and is more appropriate for the child and adolescent than the existing classification schemes of Wiltse-Newman and Marchetti-Bartolozzi. Algorithms for evaluation and treatment of spondylolysis and spondylolisthesis in children and adolescents, based on this new classification, are presented.

Ultrasound-guided aspiration of the hip in children: a new technique.

Evaluation of the child presenting with an irritable hip often requires aspiration of the hip. There are various methods for doing this procedure. We present a new technique for hip aspiration using high-resolution ultrasound imaging with color Doppler and a needle guide. This technique maximizes chances for a successful aspiration, minimizes risks to the child, avoids radiation exposure, and is easy to do and teach.

Septic arthritis in a patient with juvenile rheumatoid arthritis.

The acute flare of joint inflammation in the child with known juvenile rheumatoid arthritis causes concern primarily regarding the need for additional or modified medical treatment. Acute joint inflammation in an otherwise healthy child creates concern regarding the existence of joint infection. In the early phase of disease, the clinical findings and symptoms of an inflamed joint attributable to juvenile rheumatoid arthritis or infection may be similar and difficult to differentiate from the other. Juvenile rheumatoid arthritis usually is well controlled by medical interventions, however, the initiation of specific treatment is more urgent in children with joint sepsis. The following case report is presented to emphasize the difficulty in evaluation of patients with known juvenile rheumatoid arthritis and coexistent septic arthritis, and to discuss the methods used to differentiate between the two conditions.

Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability.

This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement < or =3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.