VEPTR: Are We Reducing Respiratory Assistance Requirements?

BACKGROUND: The assisted ventilation rating (AVR) indicates the degree of external respiratory support required in children with thoracic insufficiency syndrome (TIS) and early onset scoliosis. For skeletally immature patients with TIS, the vertical expandable prosthetic titanium rib (VEPTR) device can be used to improve lung volume and growth. We hypothesized that patients who underwent early thoracic reconstruction by VEPTR treatment had an improved respiratory status. METHODS: Preoperative and postoperative AVR ratings were prospectively collected in a multicenter study group and compared to determine change after VEPTR treatment. Patients under 10 years of age at initial implant with minimum of 2-year follow-up data were included. Patients were excluded if there were incomplete data or if initial AVR was normal (breathing on room air). Statistical analysis was performed on groups which had stable, declined, and improved AVR at final follow-up. RESULTS: Database search yielded 77 patients with initial abnormal AVR. Average follow-up was 5.6 years. The most frequent primary diagnoses were congenital scoliosis (n=14) and spinal muscular atrophy (n=14). In total, 19 (24%) demonstrated improvement, 9 (12%) patients deteriorated, and 49 (64%) remained at the same level. The average preoperative major curve in those with improvement (58.4 degrees) and those with no change (63.5 degrees) was less than in those with deterioration (85.5 degrees) (P=0.014). The average age in years at implant of those with improvement (4) was less than those declined (6.7) and those with no change (5.5). In total, 16 (84.2%) of those that improved had a normal AVR and did not require respiratory support at last follow-up. CONCLUSIONS: There is evidence that a subset of patients with early onset scoliosis and TIS who received early thoracic reconstruction with VEPTR treatment show complete resolution of pulmonary support at final follow-up. In total, 89% of 79 patients did not experience respiratory deterioration. A total of 24% (n=19) had a positive change with over 84% (n=16) of this group no longer requiring support. LEVEL OF EVIDENCE: Level III-prognostic.

Pediatric femoral shaft fractures: a system for decision making.

Pediatric femoral shaft fractures are one of the most common major pediatric injuries treated by orthopaedic surgeons. Historically, casting, with or without traction, was the standard of care for almost all pediatric femoral fractures. However, during the past 15 years, there has been a trend toward surgical fixation and rapid mobilization. This evolution has given orthopaedic surgeons many treatment methods in which they must consider patient age and size, fracture pattern, and the surgeon's own skills and experience. The evolution away from casting, with or without traction, has led to seven treatment options: (1) a Pavlik harness with or without a splint, (2) a walking spica cast, (3) a standard spica cast with or without traction, (4) elastic intramedullary nailing, (5) submuscular plating, (6) external fixation, or (7) trochanteric-entry intramedullary nailing. To determine which treatment option is best for a specific fracture type in a specific patient, pediatric femoral shaft fractures can be divided into five classes: (1) fractures that will heal with limited intervention; (2) fractures that should be treated without surgery, but must be watched closely; (3) fractures that benefit from surgical intervention with load-sharing implants; (4) fractures that may benefit from surgical intervention with rigid fixation; and (5) fractures in a patient with a limb at risk and associated injuries that require initial treatment precedence.

Patella Sleeve Fracture with Medial Patellofemoral Ligament Tear and Lateral Femoral Condyle Fracture in an Adolescent: A Case Report.

CASE: A 12-year-old boy sustained a patella sleeve fracture of the superior pole, medial patellofemoral ligament tear, and lateral femoral condyle fracture after a direct contact sledding injury. He was managed nonoperatively with 5 weeks of cylinder cast immobilization with transition to a hinged knee brace and physiotherapy. By 3 months, he returned to sport activity without patellar instability. CONCLUSION: This is the first case to describe simultaneous development of these 3 injuries in an adolescent. We recommend that patients with patella sleeve fracture undergo magnetic resonance imaging to assess for local soft-tissue injury because this may influence treatment decisions.

Monkey Bar Dimensions Associated with Pediatric Upper Extremity Fractures Show Deviations from United States Product Safety Commission Recommendations.

Background Monkey bar injuries account for the majority of playground injuries, and 34% result in a fracture. Studies have shown that there has been no decline in the number of monkey bar injuries over several decades. Our goal was to focus on fractures of the upper extremity resulting from monkey bar injuries. Additionally, we set out to analyze the dimensions of the monkey bar apparatus on which the injury occurred and determine if they were compliant with those recommended by the United States (US) Product Safety Commission. Methods A retrospective chart review of all upper extremity injuries seen in a large pediatric orthopedic practice in 2017 was conducted to find all monkey bar-related injuries. Data was collected including age at the time of injury, gender, and injury type. Families of the injured child were contacted to identify the exact location of the injury. On-site measurements were made of the monkey bar apparatus including height, the distance between grips, the circumference of the grip, and ground surface type. Results Of 1968 patients seen in 2017, there were 990 upper extremity injuries and 66 monkey bar injuries (98.5% fractures). The average age of those injured on monkey bars was 6.6 ± 1.9 years, 60.6% were males. The average height of the apparatus was 207.32 ± 16.59 cm (range: 176.53-254 cm), the average distance between grips was 35.30 ± 5.62 cm, and the average circumference of the grip was 9.83 ± 1.03 cm. All exceeded the recommended height for preschool children aged 4-5 years (152.4 cm), and 11 of the 30 (36.7%) exceeded this recommended height for school-age children (213.26 cm). For the distance between grips, 23 of the 30 (76.7%) exceeded the preschool recommendation (30.48 cm), and three of 30 (13.3%) monkey bars exceeded the recommendation for school age children (38.1 cm). Conclusion Monkey bar injuries continue to be a common source of upper extremity fractures among young children. There is a high rate of non-compliance with current recommended safety standards.

Pediatric Orthopedic Trauma.

The management of pediatric orthopedic trauma continues to evolve rapidly. Whereas the strong healing potential of pediatric patients often allows for the nonoperative treatment of most conditions, many injuries require urgent operative treatment to ensure that patients may return to all activities without disability. Some injuries may require additional follow-up and interventions, as complications such as growth arrests or deformity may occur. This article summarizes the most common fractures and orthopedic injuries of the pediatric patient. The keys to diagnosis, acute management, nonoperative and operative treatments, and complications are discussed. The detection and management of nonaccidental trauma are also examined.

Cascading Adjacent Level Vertebral Compression Fractures Necessitating a Series of Eleven Kyphoplasties.

Vertebral kyphoplasty is a procedure used for the treatment of compression fractures. While early randomized-controlled trials were equivocal regarding its benefits, more recent RCTs have shown favorable results for kyphoplasty with regard to pain relief, functional recovery, and health-care related quality of life compared to control patients. Risks of kyphoplasty include but are not limited to cement extrusion, infection, hematoma, and vertebral body fracture of adjacent levels. We describe a case of a 66-year-old male attorney who underwent eleven kyphoplasties in an approximately one-year period, the majority of which were for fractures of vertebrae adjacent to those previously treated with kyphoplasty. Information on treatment was gathered from the patient's hospital chart and outpatient office notes. Following the last of the eleven kyphoplasties (two at T8, one each at all vertebrae from T9 to L5), the patient was able to function without pain and return to work. His physiologic thoracic kyphosis of 40 degrees prior to the first procedure was maintained, as were his lung and abdominal volumes. We conclude that kyphoplasty is an appropriate procedure for the treatment of vertebral compression fractures and can be used repeatedly to address fractures of levels adjacent to a previous kyphoplasty.