Pathologic fractures in children with acute Staphylococcus aureus osteomyelitis.

BACKGROUND: Osteomyelitis is a common pediatric musculoskeletal infection. This infection can weaken the normal bone structure, resulting in the risk of a pathologic fracture. The purpose of this study was to evaluate the risk factors for pathologic fracture in children with Staphylococcus aureus osteomyelitis. METHODS: Seventeen children who were treated for a pathologic long-bone fracture secondary to Staphylococcus aureus osteomyelitis between January 2001 and January 2009 at a tertiary-care pediatric hospital were identified. These patients were compared with a control group consisting of forty-nine children with Staphylococcus aureus osteomyelitis without a fracture who were matched for age, sex, and methicillin susceptibility. A retrospective review of the clinical records, magnetic resonance imaging (MRI) studies, and microbiologic findings was performed. RESULTS: Patients who developed a fracture presented with osteomyelitis at a mean age of 8.8 years (range, two to seventeen years). Fifteen of the seventeen patients had methicillin-resistant Staphylococcus aureus (MRSA) isolates, and two had methicillin-susceptible Staphylococcus aureus (MSSA). The mean time from disease onset to fracture was 72.1 days (range, twenty to 150 days). The duration of hospitalization, number of surgical procedures, duration of antibiotic treatment, and total number of complications differed significantly between the two groups. MRI studies at the time of admission demonstrated a significantly greater prevalence of subperiosteal abscess and greater circumferential size of such an abscess in the patients with a fracture. A sharp zone of abnormally diminished enhancement of the marrow was also more common in these patients. The USA300-0114 pulsotype was more commonly associated with an elevated likelihood of fracture. CONCLUSIONS: Staphylococcus aureus osteomyelitis is a serious infection that may predispose children to pathologic fractures. Protected weight-bearing and activity restriction are recommended in children with Staphylococcus aureus osteomyelitis who have the risk factors demonstrated in this study.

The role of lateral-entry Steinmann pins in the treatment of pediatric supracondylar humerus fractures.

PURPOSE: Loss of pin fixation in supracondylar fractures can occur with failure to achieve bicortical fixation. Bicortical fixation may be challenging for those pins that attempt to penetrate the diaphyseal cortex, where the bone is thick. Lateral-entry Steinmann pins may allow for better penetration through cortical bone because they are more rigid than typical Kirschner wires. METHODS: A retrospective review of 16 children with type III supracondylar fractures treated by a single surgeon using Steinmann pins was undertaken. The average age at presentation was 6 years. Following closed reduction, all fractures were maintained with three lateral-entry pins. At least one Steinmann pin was placed in the lateral column of the distal humerus in each pin construct. RESULTS: Follow-up radiographs indicated a mean Baumann's angle of 72.9° (range 64°-82°). There was no statistically significant change in the Baumann's angle or axial alignment at final follow-up. All but one fracture healed in an anatomic position on the lateral view. CONCLUSIONS: Steinmann pins placed through a lateral-entry point are effective in controlling the reduction of high-grade supracondylar fractures. The fixation is excellent and avoids potential ulnar nerve complications of medial entry.

A clinical analysis of shoulder and hip joint infections in children.

BACKGROUND: Septic arthritis of the shoulder is a rare infection in healthy children. This infection requires prompt surgical drainage and antibiotic treatment. A delay in surgical intervention can result in damage to the articular surface of the glenohumeral joint, adjacent osteomyelitis, and possible growth disturbance. The clinical course of septic arthritis of the shoulder was compared with that of septic arthritis of the hip, a more common disease in children. METHODS: We identified 9 children with infections of the glenohumeral joint who presented to our pediatric hospital between 2001 and 2007. The average age at presentation was 7 years (range: 7 mo to 12 y). These patients were compared with 14 selected patients treated for septic arthritis of the hip (mean age 7 y, range: 1 to 12 y). Surgical drainage was performed by open arthrotomy in each case. A retrospective review and analysis of the medical records, laboratory tests, and radiographs of these patients were performed. RESULTS: Children with shoulder infections differed significantly (P<0.05) from patients with hip infections with regard to temperature, white blood cell count, and erythrocyte sedimentation rate at the time of admission. The average time from the onset of symptoms to presentation was notably longer in the shoulder group compared with the hip group (P=0.012). Adjacent osteomyelitis was found in 67% of the shoulders and 36% of the hips (P=0.214). Children suffering from septic arthritis of the shoulder showed higher rates of repeat surgical drainage (P=0.056) and extended hospitalizations (P=0.028). The total duration of antibiotics was longer in the shoulder group (P=0.059). CONCLUSIONS: Septic arthritis of the shoulder in the pediatric population often has a delayed presentation with a more complicated disease course than an infection of the hip. Children with shoulder infections require a longer duration of treatment and may experience a higher likelihood of skeletal complications. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Iliac apophyseal displacement: an alternative in pediatric pelvic osteotomies.

The traditional surgical exposure for a Salter or Chiari pelvic osteotomy involves splitting the iliac apophysis to facilitate subperiosteal separation of the muscles of the inner and outer table of the ilium. With healing, the iliac crest frequently becomes broad and prominent, and the iliac wing hypoplastic. We addressed this issue by separating the whole iliac apophysis laterally at the junction of cartilage and bone and displacing it medially. The ilium was then exposed by subperiosteal dissection of the inner and outer table musculature. From February 1988 to June 2000, twenty-five pelvic osteotomies were performed utilizing this approach. Satisfactory exposure was achieved in each case. All osteotomies healed without iliac growth disturbances, leaving excellent cosmetic results. Resuturing the previously elevated external oblique abdominus over the iliac apophysis further improved contour and appearance, Iliac apophyseal displacement rather than splitting provided appropriate access and consistently good function and cosmesis.

Preventive psychological services in time of war: controlled coping to foster resilience.

The sudden onset of war results in considerable psychological challenges as well as physical danger for populations under attack. While all civilian-directed violence carries common elements of fear and threat, unexpected consequences of war often require coping strategies to be adaptive, flexible, and effective. The Hezbollah-Israel confrontation of 2006 created such unanticipated consequences for many residents of northern Israel. Although the population was experienced in dealing with years of terror and war extended stays in bomb shelters and the intensity of the attacks created additional stressors that were out of the ordinary for most residents of the war zone. We describe an intervention technique, "controlled coping, "that is designed as a first aid mechanism for such populations in similar conditions.

Management of long toe flexor spasticity in the equinus foot in cerebral palsy.

Toe flexor tightness becomes apparent in the plantigrade attitude achieved by isolated tendoachilles lengthening in cerebral palsy. This frequently persists, resulting in abnormal weight-bearing on the tips of the toes. To address this problem, at the time of limited tendoachilles lengthening, we performed Z-lengthenings of the flexor hallucis longus and the flexor digitorum longus tendons above the medial malleolus, preserving the pulley mechanism. From January 1998 to October 2001, 41 children (74 feet) with cerebral palsy underwent lengthening of the tendoachilles and long toe flexor tendons. The mean age at surgery was 7 years. The correction achieved was successfully maintained long-term, permitting a normal heel-metatarsal head weight-bearing pattern. Lengthening of the long toe flexors, in conjuction with tendoachilles lengthening, is an effective means of achieving a balanced foot in cerebral palsy.

Anterior lumbar instrumentation improves correction of severe lumbar Lenke C curves in double major idiopathic scoliosis.

Fifteen skeletally immature patients with double major adolescent idiopathic scoliosis with large lumbar curves and notable L4 and L5 coronal plane obliquity were retrospectively studied. Seven patients who underwent anterior release and fusion of the lumbar curve with segmental anterior instrumentation and subsequent posterior instrumentation ending at L3 were compared with eight patients treated with anterior release and fusion without anterior instrumentation followed by posterior instrumentation to L3 or L4. At 4.5 years follow-up (range 2.5-7 years), curve correction, coronal balance and fusion rate were not statistically different between the two groups; however, the group with anterior instrumentation had improved coronal plane, near normalangulation in the distal unfused segment compared with the group without anterior instrumentation. In cases involving severe lumbar curvatures in the context of double major scoliosis, when as a first stage anterior release is chosen, the addition of instrumentation appears to restore normal coronal alignment of the distal unfused lumbar segment, and may in certain cases save a level compared with traditional fusions to L4.

Corrective supracondylar humeral osteotomies using the small AO external fixator.

Traditional methods of correcting malunited distal humeral fractures in children involve complex wedge osteotomies held with pins or internal fixation devices. These require a large exposure and challenging fixation. We elected to perform simple transverse osteotomies, without wedges, using a lateral incision. These were maintained by the small AO external fixator. Between 1987 and 2004, five children with malunited distal humeral fractures were treated. Angular and rotational correction was obtained in each case. Bony union occurred at an average of 8 weeks. A simple osteotomy held by the small AO external fixator provides accurate correction, precise adjustability, and solid stability.

The role of the small AO external fixator in supracondylar rotational femoral osteotomies.

Torsional problems of the femur have been traditionally treated by a proximal osteotomy with internal fixation. We elected to perform femoral derotational osteotomies distally. Between September 1994 and April 2001, supracondylar osteotomies were performed on 38 femora in 21 children with torsional and angular deformities. The average age was 9 years (range 5-15 years). Twenty-three femora had excessive anteversion and fifteen, retroversion. All osteotomies were maintained by the small AO external fixator. Bony union occurred at an average of 10 weeks. Distal femoral osteotomy is an effective site for correcting rotational and associated angular deformities. The small AO external fixator provides precise adjustability, solid stability, and avoids a second procedure for hardware removal.

Periosteal chondrosarcoma in a 9-year-old girl with osteochondromatosis.

A 9-year-old girl with multiple osteochondromatosis presented with a 1 year history of a gradually enlarging surface lesion originating from the midsection of the right humerus, distal to an osteochondroma. Radiographically and histologically this lesion proved to be a periosteal chondrosarcoma adjacent to an osteochondroma.

The role of AO external fixation in proximal femoral osteotomies in the pediatric neuromuscular population.

Internal fixation in proximal femoral osteotomies using traditional devices may be sub-optimal in children with neuromuscular disorders who have small or osteopenic bone. In this population, between 1988 and 2000, we performed 36 proximal femoral varus osteotomies in 28 patients. These were controlled by the AO external fixator. The average age at surgery was 7 years (range, 2-13 years). A mean varus correction of 34 degrees (range, 15-90 degrees) was obtained. Complications consisted of one superficial pin tract infection, one skin breakdown, and one non-union. Other than the non-union, all osteotomies were stable at the time of the fixator removal. The AO external fixator is an effective alternative in maintaining corrective proximal femoral osteotomies in children with fragile bones.

Infections of the spine: what the orthopedist needs to know.

Infections of the spine usually present with back pain in the absence of constitutional symptoms. Diagnosis requires a high index of suspicion and appropriate radiological and laboratory studies. Most infections can be managed conservatively with organism-specific antibiotics and bracing with good success. Surgery may be indicated to isolate the offending organism and to manage neurological and structural complications.

Etiology, treatment, and prevention of athletic "stingers".

Stingers or burners are common in athletes, especially football players. They represent a traction, compression, or direct blow to the upper roots of the brachial plexus. They are usually transient and resolve quickly. Cervical canal stenosis with concurrent degenerative disc disease may predispose an athlete to this injury. Return-to-play criteria are largely based on the number of previous episodes and the duration of symptoms. These criteria also require appropriate consideration of any underlying pathological conditions. Appropriate counseling, including modification of tackling and addition of protective gear, in conjunction with complete rehabilitation, may be effective in preventing this condition or decreasing the rate of recurrence. The athlete, family, and coaches need to understand that recurrence remains unpredictable.