Radiographic clues to the unstable knee: are findings of trochlear dysplasia on lateral knee radiographs reliable and predictive of patellar dislocation?

BACKGROUND: Trochlear dysplasia (TD) is a key predisposing risk factor for patellar instability (PI) and lateral patellar dislocation (LPD) injuries. It is useful to understand the reliability of radiographic findings of TD and the accuracy of knee radiographs in diagnosing patients with recent LPD. PURPOSE: The purposes of our study are to evaluate the inter-rater reliability of specific radiographic signs of PI and staging of TD between radiologists and orthopedic surgeons, and to identify which findings are associated with recent LPD. METHODS: This retrospective study comprised 336 patients aged 8 to 18 who obtained knee radiographs over a 3-year period. Two radiologists and two orthopedic surgeons, blinded to patient history, examined radiographs for indicators of PI. Using data from 19 confirmed LPD cases and 317 controls, inter-observer agreement (kappa, Pearson's correlation coefficient) was assessed, as was the odds ratio for likelihood of LPD. RESULTS: There was nearly perfect agreement between radiologists for patella-tendon ratios (Pearson's correlation coefficient 0.8377, P < 0.0001) and discrimination between normal knees and high-grade TD (kappa 0.9213, P < 0.0001). There is fair agreement between radiologists and surgeons distinguishing between normal knees and high-grade TD (kappa 0.5843, P < 0.0001). Lateral knee radiographs interpreted as high-grade TD were highly predictive of LPD (odds ratio 7.58-54.8) among all readers. CONCLUSIONS: There is high agreement between radiologists when evaluating lateral knee radiographs for signs of TD, validating the results of prior literature. Radiographic findings TD, patella alta, and effusion are variable predictors of recent LPD, greatest among patients with TD.

High rate of inappropriate referrals to pediatric orthopedics in an egalitarian healthcare system.

Previous studies have shown relatively high rates of inappropriate referrals to pediatric orthopedic surgery. The purpose of this study was to determine the rate of inappropriate referrals in an egalitarian healthcare system. We reviewed all 400 referrals to our pediatric orthopedic surgery practice over a 2-year period and assessed the appropriateness of each based on the American Academy of Pediatrics guidelines. A total 206 (52%) referrals were deemed appropriate. There is a high rate of inappropriate referral to pediatric orthopedic surgery even within a closed, egalitarian healthcare system. Targeted education of primary care providers may help reduce this rate.

Bilateral Crush Injury of the Proximal Tibial Physis in an Adolescent Gymnast: A Case Report.

CASE: A thirteen-year-old female gymnast experienced bilateral knee pain after landing from a jump off a vault during a competition. Initial radiographs revealed negative findings, but magnetic resonance imaging demonstrated periphyseal osseous edema of the proximal parts of the tibiae. The patient later developed an anterior physeal bar on the right side, with recurvatum deformity. CONCLUSION: Despite similar initial imaging findings bilaterally and identical mechanisms of injury, only the injury on the right side met the strict criteria for classification as a Salter-Harris type-V injury. This case illustrates the difficulty encountered with current diagnostic criteria for type-V injuries.

Return to duty after elective fasciotomy for chronic exertional compartment syndrome.

BACKGROUND: Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study's purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population. METHODS: A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months. RESULTS: Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service. CONCLUSION: Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations. LEVEL OF EVIDENCE: Level IV, case series.

Isolated ring finger flexor digitorum profundus entrapment after closed reduction and intramedullary fixation of both-bone forearm fracture.

Flexor tendon entrapment after a pediatric forearm fracture is a rarely reported complication that is often diagnosed late. Flexor tendon entrapment is more frequently reported after distal forearm fractures, and possible etiologies include fibrosis secondary to hemorrhage at the fracture site and simple entrapment of the muscle belly.This article describes a case of ring finger flexor digitorum profundus entrapment in a 12-year-old boy with a closed both-bone forearm fracture that was treated with closed reduction and intramedullary nail fixation. Preoperatively, the patient had full flexion and extension of all fingers. The entrapment was noted at the first postoperative follow-up when the patient could fully extend the ring finger proximal interphalangeal joint but was unable to concomitantly extend the metacarpal phalangeal joint. Magnetic resonance imaging and ultrasound were obtained to identify the entrapment site. Intraoperatively, a portion of the flexor digitorum profundus musculotendinous junction was entrapped in the fracture site. After release of the entrapment, the patient gained immediate passive range of motion. Subsequently, the hardware was removed, and the patient healed and regained full ring finger function. To the authors' knowledge, this is the only report of isolated ring finger flexor digitorum profundus entrapment after closed reduction and intramedullary fixation of a pediatric forearm fracture. The authors recommend vigilant physical examination of passive and active range of motion of all digital joints with the wrist in flexion and extension before and after bony manipulation.