Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices.

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

Unique Considerations for Paediatric Proximal Phalanx Fractures.

Paediatric hand fracture care presents unique considerations and challenges. The proximal phalanx is the most injured location. This review details pearls for the examination of the injured paediatric hand, immobilisation considerations and treatment strategies. Over-treatment can lead to unnecessary stiffness, missed activities, increased healthcare costs or unnecessary surgical morbidity. Undertreatment can promote malunion and dysfunction. Fracture patterns discussed include those of the phalangeal head, neck, shaft and base. The concepts covered will help optimise the evaluation and treatment of children with injured proximal phalanges. Level of Evidence: Level V (Therapeutic).

Late Flexor Entrapment in Neocortex After Pediatric Forearm Fracture: A Case Report.

CASE: A pediatric patient sustained an open Monteggia-equivalent fracture treated operatively. Despite uneventful fracture healing, late-onset extrinsic flexor tightness of the index finger occurred. A neocortex developed about the torn ulnar periosteum, entrapping the index flexor digitorum profundus muscle belly. Despite being 5 years postinjury, motion was improved after proximal muscle release. CONCLUSION: Acute flexor entrapment is well-reported in forearm fractures; however, late-onset entrapment inside a neocortex is not. Although early recognition of restricted motion is ideal, even long-standing contractures may be amenable to improvement with appropriate treatment guided by the physical examination.

Streamlining Postoperative Care After Pediatric Supracondylar Humerus Fractures: Is Follow-up After Pin Removal Routinely Needed?

BACKGROUND: Closed reduction and percutaneous pinning is the standard of care for displaced supracondylar humerus fractures (SCHFs). Although the operative management of SCHFs has achieved good consensus with low complication rates, there remains a paucity of literature on postoperative management. We hypothesized that routine office visits after pin removal can safely be avoided in uncomplicated SCHFs without compromising patient care. METHOD: A retrospective review was conducted to query the electronic medical record for SCHFs, treated with closed reduction and percutaneous pinning. Patients with complicated SCHFs were excluded. Patients were divided into 2 cohorts: follow-up (FU) and nonfollow-up (NFU), depending on the presence or absence of after-pin removal (APR) FU visits. Demographics, surgical variables, number of x-rays, referrals for physical therapy, total FU visits, complications, and clinical events after pin removal up to 3 months were compared. Subgroup analysis was performed according to Gartland fracture types. RESULTS: A total of 179 patients were included in the study, 111 in the FU group and 68 in the NFU group. There were no significant differences found in demographics between the 2 groups. There were no significant differences in complications and APR clinical events between 2 groups (P>0.05). An average of 1.98 additional x-rays were taken APR in FU group. None of the NFU group patients required physical therapy. Excluding patients with pin site infections, 15/108 (13.9%) of FU group patients had >1 APR visits. SUMMARY: For operatively managed uncomplicated SCHFs, patients who do not have routinely scheduled FU APR have no greater incidence of clinical events APR than patients with a scheduled FU. With a detailed discussion including expectations, timeframe for resuming activities, home exercises, and reassurance of the ease of FU if desired, routine FU APR can be safely eliminated after uncomplicated SCHFs in order to streamline postoperative care. LEVEL OF EVIDENCE: Level III.

Pediatric Scaphoid Fracture Associated with Osteopetrosis: A Case Report.

CASE: A 12-year-old boy with osteopetrosis sustained a scaphoid waist fracture, which has not previously been reported with this condition. Healing was successfully achieved with percutaneous cannulated compression screw fixation, albeit with prolonged healing as is typical for this condition. CONCLUSION: A lack of osteoclastic remodeling predisposes patients with osteopetrosis to fractures, commonly in long bones. Increased risks of infection, anesthesia, and broken hardware along with limited ability to compress bone may discourage operative management. Internal fixation should still be considered in select cases to limit displacement while allowing early range of motion.

The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making.

Multilevel surgery for upper extremity spasticity is the current surgical standard. While the literature details surgical techniques and outcomes, a comprehensive guide to surgical planning is lacking. Patients commonly present with posturing into shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion with ulnar deviation, finger flexion, and thumb adduction, although variations exist. Multiple surgical options exist for each segment; therefore, repeated examinations for contracture, pathologic laxity, and out of phase activity are necessary to optimize the surgical plan. To avoid decreasing function, one must carefully balance the benefits of contracture release and tendon transfers with their weakening effects. In certain cases, stability from joint fusion outweighs the loss of motion. Failure to recognize dynamic posturing, grasp and release requirements, or hand intrinsic spasticity can worsen function and cause new deformities. Surgical indications are formulated for individual deformity patterns and severity along with personal/family goals. General comprehension, voluntary control, and sensation, although not modifiable, influence decision making and are prognostic indicators. Functional improvement is unlikely without preexisting voluntary control, but appearance and visual feedback may be improved by repositioning nonetheless. Appropriate interventions and management of expectations will optimize limb appearance and function while avoiding unexpected sequelae.

Extensor Pollicis Longus Tendon Rupture After a Pediatric Distal Radius Fracture: A Case Report and Literature Review.

CASE: A 16-year-old boy underwent closed reduction and pinning of a Salter-Harris II distal radius fracture (DRF). Extensor pollicis longus (EPL) rupture occurred 6 weeks after the injury. Extensor indicis proprius transfer was performed using wide-awake local anesthesia no tourniquet (WALANT) technique. Active thumb range of motion was restored, and the patient returned to all activities, including sports, after 2 months. CONCLUSION: Although delayed attritional EPL rupture after DRF is a well-known complication in adults, this is the first reported case in a truly skeletally immature patient. Awareness of this complication prompts monitoring for prodromal signs and symptoms. The WALANT technique is feasible in selected children.

Updates on and Controversies Related to Management of Radial Nerve Injuries.

Radial nerve injuries are among the most common major traumatic peripheral nerve injuries. Recent literature has updated our knowledge of aspects ranging from radial nerve anatomy to treatment options. Observation and tendon transfers were, and still are, the mainstays of management. However, the improved outcomes of nerve repair even 5 months after injury have changed the treatment algorithm. Nerve repair techniques using conduits, wraps, autograft, and allograft allow tension-free coaptations to improve success. Nerve transfers have evolved to allow a more anatomic recovery of function if used in a timely manner. This review offers an update on radial nerve injuries that reflects recent advances.

Upper Extremity Care for Children: Unique Medical and Psychosocial Aspects.

Hand surgeons encountering pediatric patients should be attuned to both technical and practical facets of caring for congenital and traumatic pathologies. Psychosocial aspects include engaging children in conversation and factoring in both self and external perception of deformity. Medical considerations are also unique, from including child abuse in the differential to having techniques to assess active motion and sensation in the nonverbal child. Certain universal principles, such as minimizing radiation exposure and limiting needle sticks, have higher emphasis in pediatric patients than in adults. With these aspects in mind, treating children and their families can be a mutually rewarding experience.

Tibial hemimelia associated with GLI3 truncation.

Tibial hemimelia is a rare, debilitating and often sporadic congenital deficiency. In syndromic cases, mutations of a Sonic hedgehog (SHH) enhancer have been identified. Here we describe an ~5 kb deletion within the SHH repressor GLI3 in two patients with bilateral tibial hemimelia. This deletion results in a truncated GLI3 protein that lacks a DNA-binding domain and cannot repress hedgehog signaling. These findings strengthen the concept that tibial hemimelia arises because of failure to restrict SHH activity to the posterior aspect of the limb bud.

Reinforcing a spica cast with a fiberglass bar.

Hip spica casting is used in the treatment of femur fractures and hip dysplasia in children 1 to 6 years old. A bar connecting the legs of the cast has been shown to improve cast integrity and assist in patient transport. We present a simple and low-cost technique that can be used to create a connecting bar and that can be performed with readily available casting materials.

Pediatric Posterior Sternoclavicular Joint Injuries.

Posterior sternoclavicular joint injuries are increasingly diagnosed in children and young adults. Most of these injuries are the result of indirect mechanisms, typically lateral compression, with a posterior-to-anterior force applied to the shoulder during sports. Less frequently, these injuries are caused by direct impact on the medial clavicle, which can occur in rollover motor vehicle accidents, or may represent atraumatic instability. In patients younger than 25 years, physeal separation is more common than true dislocation. Theoretically, these patients have increased remodeling potential. Reduction is recommended to prevent and/or manage the compression of mediastinal structures, which can lead to life-threatening injury. Open surgical stabilization is the preferred treatment for acute and chronic retrosternal injuries. A thoracic or trauma surgeon should be available during stabilization in the rare event of potentially life-threatening hemorrhage after reduction. Outcomes have been largely successful, with pain-free, unrestricted range of motion and return to activity.

Legg-Calvé-Perthes disease: an overview with recent literature.

The evolving knowledge on Legg-Calvé-Perthes (LCP) demonstrates the utility of studying a rare disease systematically by piecing together the biology and mechanics of this condition and applying clinical observations to improve patient care. As treatments of less common diseases are hard to randomize and study in meaningful numbers, long-term study groups have been created to provide insight into this entity that remains an enigma in many aspects. These studies permit a more evidence-approached guide to prognosis and treatment. Meanwhile, basic science research contributes to our understanding of pathophysiology of the disruption and repair processes that lead to LCP, with the goal of clinical translation. This review of LCP aims to give an overview of the condition, with specific focus on recent literature.

Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up?

PURPOSE: Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients' current functional level, satisfaction, and pain; and (3) current arthropometric measurements. METHODS: Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti's functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones. RESULTS: The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1-10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions. CONCLUSIONS: Revision clubfoot surgery with calcaneocuboid fusion in patients 5-8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.

High-pressure paint gun injection injury to the palm.

High-pressure injection injuries often have a misleadingly benign presentation. However, it is important to recognize the potential surgical urgency and long-term sequelae associated with these injuries. We present a case of paint gun injection to the palm and review the literature on high-pressure paint injection injuries. The 3 factors most important for the fate of the limb are material type, injection pressure, and injury site. The immediate use of antibiotics and tetanus prophylaxis, with or without steroids, is indicated. Urgent debridement in the operating room is imperative and can decompress the neurovascular structures and flexor tendon sheath by removing the irritating agents. Reported overall amputation rates have been as high as 30%.

Bipolar latissimus transfer for restoration of elbow flexion.

BACKGROUND: Elbow flexion is often lacking in patients with brachial plexus palsy or anterior arm trauma. Restoring elbow flexion helps position the functioning hand for activity and nonfunctioning hand for stabilization. Bipolar latissimus transfer is one method of improving elbow flexion. METHODS: A clinical case of bipolar latissimus transfer is presented. Additionally, results of a literature search are incorporated. RESULTS: Bipolar latissimus can effectively improve elbow function, however residual deficits are to be expected. Additional transfers include unipolar latissimus, triceps, sternocleidomastoid, and pectoralis. Other methods include primary nerve transfer, Steindler flexorplasty, free muscle transfer, and elbow fusion. CONCLUSION: Elbow flexion can be improved through various techniques. Each individual's clinical picture should be examined by an experienced clinician when choosing which technique to apply.

Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection?

BACKGROUND: Many institutions perform radiographic documentation following splint application even when no manipulation had been performed. The purpose of this study was to evaluate the utility of post-splinting radiographs of acute non-displaced or minimally displaced fractures that did not undergo manipulation. Our hypothesis was that post-splinting radiographs do not demonstrate changes in fracture alignment or impact the management of the patient. METHODS: After institutional review board exemption had been granted, consultations performed by orthopaedic residents at a level-I trauma center from September 2008 to April 2010 were reviewed. Of 2862 consultations, 1321 involved acute fractures that were splinted. Radiographs revealed that 342 (25.9%) of the fractures were non-displaced or minimally displaced and angulated (defined as <5 mm and <10°, respectively) and 204 of them had been assessed with radiographs after splinting. Consults were reviewed to ensure that the patients had not undergone manipulation prior to or during splinting. Consult notes and radiographs obtained in the emergency room (ER), as well as follow-up radiographs, were reviewed to assess ultimate outcome. RESULTS: None of the 204 fractures (134 non-displaced and seventy minimally displaced) changed alignment following splinting. Two splints were reapplied, and the fractures sites were reimaged for undocumented reasons. Patients were subjected to an average of ten radiographs (range, four to twenty-five radiographs) of their extremities in the acute setting. On average, three post-splinting radiographs (range, one to ten radiographs) were obtained. The mean time between the initial and post-splinting radiographs was three hours and thirty minutes (range, nine minutes to twenty-four hours). The most common injury was a fracture about the hand or wrist. The 122 patients with that type of injury waited an average of almost three hours for an average of three post-splinting radiographs, contributing to a total of nine radiographs performed acutely. ER visits tended to be longer for patients with post-splinting radiographs compared with those without them (p = 0.06). Follow-up radiographs were available for eighty-two patients. All fractures demonstrated maintained alignment. CONCLUSIONS: Post-splinting radiographs of non-displaced and minimally displaced fractures that do not undergo manipulation before or during immobilization are associated with longer ER waits, additional radiation exposure, and increased health-care costs without providing helpful information. While certain circumstances call for additional imaging, routine performance of post-splinting radiography of non-displaced or minimally displaced fractures should be discouraged.

Progression of idiopathic clubfoot correction using the Ponseti method.

The Ponseti technique involves sequential clubfoot correction by abduction, supination, and finally dorsiflexion. Although shown to be effective, correction progression has not been examined. The Dimeglio/Bensahel classification system was used to analyze heel equinus, varus, midfoot rotation, adduction, posterior crease, medial crease, and cavus initially and after each casting. From 2000 to 2008, 123 patients (185 feet) with idiopathic clubfeet, aged below 60 days, without prior treatment were grouped by number of casts required. Successive castings achieved goals of reducing cavus and medial crease first, then gradually correcting midfoot rotation, adduction, and heel varus. Unexpectedly, heel equinus improved simultaneously with midfoot variables, as well as with final casting.

Who needs autologous blood donation in joint replacement?

Conflicting results are available about the efficacy of routine preoperative autologous donation (PAD) in reducing allogenic blood transfusion during total joint arthroplasty (TJA). This study aimed to determine if PAD is effective in reducing the need for allogenic transfusion after TJA. For this retrospective study, data on 409 patients who received total knee arthroplasty (TKA) and 513 who underwent total hip arthroplasty (THA) from January to June 2005 were evaluated. It is our institutional policy to offer preoperative donation to all patients. Based on patient decision, preoperative hemoglobin, and other factors, PAD may or may not take place. Five hundred forty-six (61%) patients donated on average 1.3 units (range, 1 to 2) of blood. Autologous and allogenic transfusions were respectively performed in 91% (514 patients) and 24% of our cohort. The rate of allogenic transfusion after TKA was lower in the PAD group at 21% versus 27% among the nondonors, although it was not statistically significant (p = 0.10). The allogenic transfusion rate after THA was significantly lower among autologous donors (16% versus 34%, p = 0.003). Advanced age, lower body mass index, simultaneous bilateral arthroplasty, and lower preoperative hemoglobin were independently associated with increased allogenic blood transfusion. PAD seems to be effective in reducing allogenic transfusions after THA but not TKA.

Ankle injuries and fractures in the obese patient.

Ankle fractures are a common orthopedic injury. Certain ankle injuries have been associated with patient demographics such as obesity and smoking. Obese patients are more prone to severe ankle injuries. Naturally, these injuries affect the lower extremity mobility significantly, which itself is a risk factor for obesity. Although obese patients have increased complications across the board, there are specific techniques that can be used to assure the best possible outcome. The perioperative, surgical, and postoperative considerations as well as the outcomes are discussed in this article.