Tweener Fractures in Children and Adolescents.

Tweener fractures are defined as long bone or metadiaphyseal fractures in a pediatric population for which multiple treatment options may be used. It is important to focus specifically on patients nearing skeletal maturity who present with length-unstable femoral shaft fractures, both-bone forearm fractures, distal radius metadiaphyseal fractures, and adolescent tibial shaft fractures. Although there is no gold standard of treatment for any of these fracture patterns, it is important to discuss the risks and benefits, proper application, and important technical aspects of each treatment method to allow surgeons to make an informed decision and optimize surgical outcomes in this patient population.

Bone alterations of pamidronate therapy in children with cerebral palsy complicating orthopedic management.

Cerebral palsy (CP) is a heterogeneous group of disorders with different clinical types and underlying genetic variants. Children with CP are at risk for fragility fractures secondary to low bone mineral density, and although bisphosphonates are prescribed for the treatment of children with bone fragility, there is limited information on long-term bone impact and safety. Children with CP usually present overtubulated bones, and the thickening of cortical bone by pamidronate treatment can potentially further narrow the medullary canal. Our purpose was to report bone alterations attributable to pamidronate therapy that impact orthopedic care in children with CP. The study consisted of 41 children with CP treated with pamidronate for low bone mineral density from 2006 to 2020. Six children presented unique bone deformities and unusual radiologic features attributed to pamidronate treatment, which affected their orthopedic care. The cases included narrowing of the medullary canal and sclerotic bone, atypical femoral fracture, and heterotopic ossification. Treatment with bisphosphonate reduced the number of fractures from 101 in the pretreatment period to seven in the post-treatment period (P < 0.001). In conclusion, children with CP treated with bisphosphonate have a reduction in low-energy fractures; however, some fractures still happen, and pamidronate treatment can lead to bone alterations including medullary canal narrowing with sclerotic bone and atypical femoral fractures. In very young children, failure to remodel may lead to thin, large femoral shafts with cystic medullary canals. More widespread use of bisphosphonates in children with CP may make these bone alterations more frequent. Level of evidence: Level IV: Case series with post-test outcomes.

Lumbar Plexus Nerve Blocks for Perioperative Pain Management in Cerebral Palsy Patients Undergoing Hip Reconstruction: More Effective Than General Anesthesia and Epidurals.

BACKGROUND: Hip reconstruction in patients with cerebral palsy (CP) is associated with. significant postoperative pain. However, adequate analgesia can be difficult to achieve. in this population due to spasticity, communication barriers, and postoperative. spasticity. Recently, multimodal pain management techniques such as epidurals and. regional nerve blocks have been described for postoperative pain control, but it is unclear if 1 technique is more beneficial. The purpose of this study was to compare the outcomes of different perioperative pain management techniques. METHODS: This study is a retrospective review of a consecutive series of children with CP over a 5-year period at a single pediatric tertiary-care hospital who underwent hip reconstruction (proximal femoral osteotomy with or without a pelvic osteotomy). Patients were subdivided based on their anesthetic protocol into the following groups: general anesthesia alone (G), general anesthesia with an epidural (E), and general anesthesia with lumbar plexus block (LPB). Our primary outcome was cumulative postoperative narcotic consumption (converted to morphine equivalents). Secondary outcomes included length of stay (LOS), average postoperative heart rate, and pain scores. analysis of variance testing was utilized to compare differences between the groups. RESULTS: Fifty-four patients who underwent hip reconstruction were included: 19 in the G group, 18 in the E group, and 17 in the LPB group. LOS was significantly higher in the E group compared with the G and LPB groups: F(2,51)=3.58, P=0.04. The average pain score was significantly lower in the LPB group compared with the others: F(2,51)=4.26, P=0.02. The average postoperative heart rate was significantly lower in the LPB group: F(2,51)=7.08, P<0.01. Postoperative narcotic consumption was significantly lower in the LPB group: F(2,51)=11.57, P<0.01. CONCLUSION: The LPB patients required the least amount of narcotics compared with the other groups. This, combined with a lower perioperative heart rate and shorter LOS would suggest these patients experienced less pain over the time of their in-patient stay. In comparison to general anesthesia alone and epidural anesthesia, lumbar plexus nerve blocks are an effective pathway for postoperative pain control after hip reconstruction in a CP population. LEVEL OF EVIDENCE: Level III-Case control or retrospective comparative study.

Should I Plan to Open? Predicting the Need for Open Reduction in the Treatment of Developmental Dysplasia of the Hip.

BACKGROUND: Closed reduction is generally attempted on children under 18 months of age who present as older infants or who fail nonoperative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will ultimately require open reduction (OR). Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. METHODS: Prospectively collected data from 4 select centers of an international multicenter study group sharing a common treatment approach were reviewed for all DDH infants under 18 months old that required operative management. Patients were categorized into 2 groups: those whose hips were successfully closed reduced or those who ultimately required OR. Factors were compared between the closed reduction and OR groups for 2 separate cohorts-those presenting early in life with ultrasound (US) data, and those presenting later with radiographic data. RESULTS: A total of 154 patients (166 hips) were included in the analysis. Overall, 87.3% were female. In the early-presenting cohort, purposeful entry multivariate regression revealed that patients with Graf IV hips on US had 3.8 times higher odds of requiring an OR. For the later cohort, hips that were clinically irreducible (ie, negative Ortolani sign) had 3.3 times higher odds of requiring OR. Patients with International Hip Dysplasia Institute (IHDI) grade IV hips had 2.5 times higher odds of needing an OR versus those with grade III hips and 15.4 times higher odds than those with grade II hips. Children with an IHDI grade IV hip and a negative Ortolani sign had 4.4 times higher odds of needing OR. CONCLUSION: Children younger than 18 months with dislocated hips who require OR are more likely to have a high-grade radiographic dislocation (IHDI grade IV), negative preoperative Ortolani sign, and a Graf IV classification on initial US. This information may help surgeons budget the use of operating room time and better counsel parents about intraoperative expectations. LEVEL OF EVIDENCE: Level III-Prognostic.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia.

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures.

BACKGROUND: Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. METHODS: Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. RESULTS: A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). CONCLUSIONS: A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. LEVEL OF EVIDENCE: Level II-economic.

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy.

BACKGROUND: Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. METHODS: Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. RESULTS: Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. CONCLUSIONS: Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. LEVEL OF EVIDENCE: Level IV-therapeutic.

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy.

PURPOSE: To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy. METHODS: Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores. RESULTS: Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM. CONCLUSIONS: Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Effects of Early Antibiotic Administration on Bacterial Culture Growth From Hand Abscesses.

BACKGROUND: Traditional management of hand abscesses consists of withholding antibiotics prior to drainage to optimize bacterial culture growth and outcome. The purpose of this study was to determine the effect of preoperative empiric antibiotics on the rate of culture growth and rate of adverse events in patients with acute hand abscesses. METHODS: We performed a retrospective review of prospectively collected data on 88 consecutive hand abscesses that received empiric antibiotics prior to incision and drainage from 2012 to 2013 at an urban academic institution. We analyzed patient demographics, bacteriology, culture growth results, time to surgery, and frequency of adverse events. RESULTS: The overall rate of positive culture growth was 90% (n = 79) despite running the antibiotics for a mean of 31 hours prior to debridement. Furthermore, 96% of the isolates were given a susceptible antibiotic during that time. The mean number of debridements was 1.5 per patient, but 4 re-operations were necessary for wound complications. No patients required an amputation or were upgraded to intensive care. CONCLUSIONS: Preoperative empiric antibiotic administration does not appear to greatly reduce bacterial culture growth from hand abscesses. The adverse events are relatively few for simple abscesses treated with pre-surgical antibiotics and decompression within 24 hours.

Pediatric Open Fractures.

Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.

Risk factors associated with clindamycin-resistant, methicillin-resistant Staphylococcus aureus in hand abscesses.

PURPOSE: To identify risk factors for clindamycin resistance in acute hand abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We performed a retrospective review of 247 consecutive culture-positive hand abscesses from 2010 to 2012 at an urban hospital. Historical and laboratory data from patients with abscesses that grew MRSA with and without clindamycin resistance were compared in a multivariate analysis. RESULTS: Methicillin-resistant Staphylococcus aureus grew on culture from 103 abscesses; 16% of those isolates were resistant to clindamycin. Multivariate analysis showed that younger age, intravenous drug use, and nosocomial acquired MRSA were significant risk factors for concurrent clindamycin resistance. Patients with a history of intravenous drug use and nosocomial acquired MRSA were, respectively, 11 and 5 times more likely to have concurrent clindamycin resistance. History of MRSA infection and human immunodeficiency virus were not identified as risk factors. CONCLUSIONS: Patients with a history of intravenous drug use or recent contact with health care facilities appear to be a potential reservoir for emerging multidrug-resistant MRSA. Selection of clindamycin as an empiric antibiotic should be especially avoided for these groups. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.