Coated Cast Saw Blades Decrease Blade Temperature During Cast Removal.

BACKGROUND: Thermal injuries can occur during cast removal with an oscillating saw. The purpose of this study is to describe the effect of blade material, blade wear, and cast material on blade temperature. METHODS: Short arm plaster and fiberglass casts were cured overnight and bivalved with either new or worn stainless-steel or tungsten-disulfide coated blades. Blade use was defined as removing 1 short arm cast. Blades used to remove more than 20 casts were defined as worn. Ten trials were performed with each combination of blade material, blade wear, and cast material, except for the combination of fiberglass and a worn stainless-steel blade due to complete erosion of cutting teeth. Thirty casts were removed with stainless-steel blades, and 40 casts were removed with coated blades. Blade temperature was measured continuously at 5 Hz using a T-type thermocouple and microcontroller board. A Mann-Whitney U test was used to compare the mean maximum temperature between groups. RESULTS: For plaster casts, new and worn stainless-steel blades produced mean maximum temperatures of 51.4°C and 63.7°C ( P =0.003), respectively. New stainless-steel blades produced significantly higher mean maximum temperatures on fiberglass casts than plaster casts (95.9°C vs. 51.4°C, P <.001). For plaster casts, new and worn coated blades produced mean maximum temperatures of 56.9°C and 53.8°C ( P =0.347). For fiberglass casts, new and worn coated blades produced mean maximum temperatures of 76.6°C and 77.7°C ( P =0.653). As with new stainless-steel blades, new coated blades produced significantly higher mean maximum temperatures on fiberglass than plaster (76.6°C vs. 56.9°C, P <0.001). Mean maximum temperatures between new stainless-steel and coated blades during removal of plaster casts were 51.4°C and 56.9°C ( P =0.131), respectively. However, new coated blades demonstrated significantly lower mean maximum temperatures during fiberglass cast removal compared to new stainless-steel blades (76.6°C vs. 95.9°C, P =0.016). CONCLUSIONS: Coated blades outperformed stainless-steel in nearly all combinations. We recommend limited use of stainless-steel blades to minimize blade temperatures during cast removal. CLINICAL RELEVANCE: Appropriate selection of blade material and monitoring blade wear minimizes blade temperature during cast removal.

The Costs of Interfacility Transfers for Nonurgent Pediatric Supracondylar Fractures.

BACKGROUND: Unnecessary transfers of nonemergent pediatric musculoskeletal injuries to regional trauma centers can be costly. The severity of fracture displacement in supracondylar humerus fractures dictates the risk of complications, the urgency of transfer and the need for surgical treatment. The purpose of this study is to examine the transfer patterns of Gartland type II pediatric supracondylar humerus fractures to identify strategies for improving patient care, improving health care system efficiency, and reducing costs. We hypothesize that there will be a high rate of unnecessary, emergent transfers resulting in increased cost. METHODS: We retrospectively identified all pediatric patients that underwent treatment for a supracondylar humerus fracture between 2013 and 2018. Patient demographics, injury characteristics, chronological data, and surgical data were collected and analyzed from ambulance run sheets, transferring hospital records, and electronic medical records. Transfer distances were estimated using Google-Maps, while transfer costs were estimated using Internal Revenue Service (IRS) standard mileage rates and the American Ambulance Association Medicare Rate Calculator. A student t test was used to evaluate different treatment groups. RESULTS: Sixty-two patients had available and complete transfer data, of which 44 (71%) patients were safely transferred via private vehicle an average distance of 51.8 miles, and 18 (29%) patients were transferred via ambulance on an average distance of 55.6 miles ( P =0.76). The average transfer time was 4.1 hours by private vehicle, compared with 3.9 hours by ambulance ( P =0.56). The average estimated cost of transportation was $28.23 by private vehicle, compared with $647.83 by ambulance ( P =0.0001). On average, it took 16.1 hours after injury to undergo surgery and 25.7 hours to be discharged from the hospital, without a significant difference in either of these times between groups. There were no preoperative or postoperative neurovascular deficits. CONCLUSION: Patients with isolated Gartland type II supracondylar humerus fractures that are transferred emergently via ambulance are subjected to a significantly greater financial burden with no demonstrable improvement in the quality of their care, since prior research has shown these injuries can safely be treated on an outpatient basis. Potential options to help limit costs could include greater provider education, telemedicine and improved coordination of care. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery.

BACKGROUND: Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery. METHODS: Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value <0.05. RESULTS: A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P=0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P=0.08). There was no difference in postoperative complication rate between groups (P=0.61). CONCLUSIONS: Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Assessment of Lateral Rotation Percentage and Rotational Deformity of the Elbow in Type 3 Supracondylar Humerus Fractures: A Biomechanical Study.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common elbow fractures in children. Historically, displaced (Gartland type 3) SCH fractures have been treated with closed reduction and percutaneous pinning. Fluoroscopic imaging is used intraoperatively in order to assess adequate reduction of the fracture fragments before pinning. On lateral fluoroscopic and radiographic images, a lateral rotation percentage (LRP) can be estimated in order to assess rotational deformity. The purpose of this study was to determine the true rotational deformity of distal humerus fracture fragments in SCH fractures based upon the LRP using a clinically relevant laterally based pinning technique. METHODS: In this study, a sawbones model was used to examine the correlation between calculated LRP and the true degree of rotational deformity with 3 of the most common extension-type SCH fracture types (low transverse, high transverse, and lateral oblique). Because fracture stability was not the focus of this study, a single pin was used to hold the construct and allow for fragment rotation along a fixed axis. In this study, 2 of the authors independently measured rotational deformity and compared this with LRP on fluoroscopic lateral imaging of a sawbones model at 0 to 45 degrees of rotational deformity. RESULTS: The LRP of all 3 patterns demonstrated a near linear increase from 0 to 45 degrees with maximum LRP measured at 45 degrees for each of the 3 patterns. Univariate linear regression demonstrated an increase in LRP for the low transverse pattern of 2.02% for every degree of rotation deformity (R2=0.97), 2.29% for the lateral oblique pattern (R2=0.986), and 1.17% for the high transverse pattern (R2=0.971). Maximum LRP was measured at 45 degrees for all 3 patterns with a mean of 53.5% for the high transverse pattern, 93.5% for the low transverse pattern, and 111.2% for the lateral oblique pattern. A higher LRP was measured with increasing degrees of rotational displacement in the low transverse and lateral oblique patterns for all degrees of rotational deformity compared to the high transverse pattern. CONCLUSION: There is a near linear correlation between the degree of malrotation and the LRP with more superior metaphyseal fracture patterns demonstrating a lower LRP than inferior fracture patterns. CLINICAL RELEVANCE: Using our data one can estimate the degree of malrotation based on the LRP on radiographs in the clinical setting. LEVEL OF EVIDENCE: Not applicable (basic-science article).

Surgical Technique: Closed Reduction and Percutaneous Pinning of Posterolaterally Displaced Supracondylar Humerus Fractures.

SUMMARY: Gartland type III posterolateral (IIIB) supracondylar humerus fractures are common among the pediatric population and can lead to concomitant injury, including compromise of the brachial artery and median nerve and long-term deformity, such as cubitus varus. These fractures can be difficult to reduce, and there is little consensus regarding the optimal technique for closed reduction and percutaneous pinning. Here, we discuss the management of Gartland III posterolateral supracondylar humerus fractures, including an in-depth technical description of the methods of operative fixation. We describe a lateral pin-only fixation technique for Gartland III posterolateral supracondylar humerus fractures that uses the intact periosteum during reduction of the distal fragment to assist in realigning the medial and lateral columns anatomically. We also discuss a safe method for placing a medial-based pin if there is persistent rotational instability at the fracture site after placement of the laterally based pins.

Pediatric Ganglion Cyst Recurrence: Location Isn't the Only Risk Factor.

INTRODUCTION: Ganglion cysts represent the most common benign soft-tissue masses of the hand and wrist, most are treated nonoperatively, with relatively few local recurrences. Few studies have identified risk factors for recurrence in the pediatric population. The aim of this study is to identify risks of cyst recurrence and to establish if ultrasonographic imaging aids in the prediction of recurrence. METHODS: A single-center retrospective chart review was performed, identifying patients diagnosed with a ganglion cyst of the hand or wrist. Demographic information, cyst characteristics, and ultrasound examination reports were documented. Standard statistical and logistic regression analyses were performed. RESULTS: A total of 132 cysts were identified in 126 patients and the average age was 8.5 years old. The most common location was the dorsal wrist (57/132, 43.2%). There were 14 recurrences [11/14, (79%) dorsal wrist, 3/14 (21%) volar wrist, 0/14 (0%) in nonwrist locations]. The risk of recurrence was significantly greater for dorsal wrist cysts than nonwrist locations (odds ratio=18.1; 95% confidence interval: 1.02, 316.65; P=0.048); there was no statistical difference in recurrence rates between dorsal and volar cysts (P=0.15). Recurrence was noted in older patients (12.2 vs. 8.1 y, P<0.001) and those patients with painful masses (P=0.02). Patients undergoing surgical excision had a higher risk of recurrence than those who did not undergo surgical excision (P<0.001). Cyst volume as measured by ultrasound was performed in 37 cysts, with repeat ultrasounds in 12 cases demonstrating a decreased volume of 0.85 cm at baseline to 0.35 cm with repeat examination (P=0.40). In patients that received at least 1 ultrasound, there were no differences in cyst volume between those that recurred and those that did not (P=0.40). CONCLUSIONS: Risk factors for recurrence in pediatric patients with a ganglion cyst include older age, symptomatic masses, cysts located around the wrist, and those requiring surgical excision. Ultrasound examination of cyst volume did not predict recurrence. LEVEL OF EVIDENCE: Level III-therapeutic.

A Salter-Harris II Distal Radius Fracture Irreducible by Closed Methods.

CASE: A 10-year-old boy presented with a Salter-Harris II distal radius fracture that was irreducible by closed methods. An open reduction was performed in the operating room where a sleeve of periosteum was found interposed between the fracture fragments. Successful reduction was performed without difficulty after the periosteum was removed from the fracture. CONCLUSION: Soft-tissue interposition must be kept in mind when having difficulty performing closed reductions of pediatric distal radius physeal fractures to avoid excessive reduction attempts.

Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis.

This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.