Diaphyseal forearm fractures in children.

Diaphyseal forearm fractures in children are common and knowledge of both ordinary and rare variations of these are important to deliver the best treatment as presented in this review. Closed reduction and cast immobilisation are effective and well-documented treatments for most fractures. Fractures which cannot be sufficiently treated in a cast are stabilised with elastic stable intramedullary nailing which is an effective treatment with a low complication rate. The focus in reduction is to correct alignment, displacement, and rotation to restore normal function of the forearm.

Supracondylar humerus fractures in children.

The supracondylar humerus fracture is the most common elbow fracture in children. All orthopedic surgeons involved in pediatric trauma will at some point have to treat this injury. Severity ranges from simple fractures to limb threatening injuries. An in-depth knowledge of this injury is key to a successful treatment outcome. This review describes the diagnostic approach and current concepts for treatment of pediatric supracondylar humerus fractures.

[Current concepts in pediatric lateral humeral condyle fractures].

Lateral humeral condyle fractures account for 10-20% of all paediatric elbow fractures. Diagnosis is made on plain radiographs; however, their interpretation is a challenge. Diagnostic MRI is used to apply the Song classification. Song stage 1-3 are managed conservatively while stage 4 and 5 are treated surgically. Closed reduction is attempted, and arthrography is used for verification. Unsuccessful reduction results in open surgery. Based on the literature, this review describes a modern algorithm for treating this injury resulting in more conservatively managed cases and less need for open surgery.

Testing basic competency in knee arthroscopy using a virtual reality simulator: exploring validity and reliability.

BACKGROUND: Diagnostic knee arthroscopy is a common procedure that orthopaedic residents are expected to learn early in their training. Arthroscopy requires a different skill set from traditional open surgery, and many orthopaedic residents feel less prepared for arthroscopic procedures. Virtual reality simulation training and testing provide an opportunity to ensure basic competency before proceeding to supervised procedures in patients. METHODS: Twenty-six physicians (thirteen novices and thirteen experienced arthroscopic surgeons) were voluntarily recruited to perform a test consisting of five arthroscopic procedures on a knee arthroscopy simulator. Performance was evaluated by obtaining predefined metrics from the simulator for each procedure, and z-scores, describing suboptimal performance, were calculated from the metrics. The intercase reliability of the simulator metrics was explored by calculating an intraclass correlation coefficient. Finally, a pass-or-fail standard was set with use of the contrasting groups method, and the consequences of the pass-or-fail standard were explored. RESULTS: One procedure was excluded from the final test because of a lack of validity. The total Z-scores for the four procedures included in the final test showed an intercase reliability of 0.87 (95% confidence interval, 0.78 to 0.93). The total mean z-score (and standard deviation) was 38.6 ± 27.3 points for the novices and 0.0 ± 9.1 points for the experienced surgeons (p < 0.0005). The pass-or-fail standard was set at a total z-score of 15.5 points, resulting in two of the novices passing the test and a single experienced surgeon failing the test. CONCLUSIONS: By combining four procedures on a virtual reality arthroscopy simulator, it was possible to create a valid, reliable, and feasible test of basic arthroscopic competency and to establish a credible pass-or-fail standard. CLINICAL RELEVANCE: The simulation-based test and pass-or-fail standard could aid in assessing and ensuring basic competency of future orthopaedic residents before proceeding to supervised procedures in patients.

[Risk of nerve damage by surgery of the lateral malleolus].

Fracture of the lateral malleolus is a common injury, which often requires surgery. The lateral approach is often used with a "cut straight to bone" method. In this 59-year-old woman with an ankle fracture we found a variant of the superficial peroneal nerve (SPN) crossing the operative field with great danger of laceration. A review of the literature reveals that in more than 10% of the cases significant nerve branches may be found in the operative field. This report emphasises the need for neurological exam and recommends that great care for nerve variants should be taken during surgery on and around the lateral malleolus.

The Danish Fracture Database can monitor quality of fracture-related surgery, surgeons' experience level and extent of supervision.

INTRODUCTION: The importance of supervision and of surgeons' level of experience in relation to patient outcome have been demonstrated in both hip fracture and arthroplasty surgery. The aim of this study was to describe the surgeons' experience level and the extent of supervision for: 1) fracture-related surgery in general; 2) the three most frequent primary operations and reoperations; and 3) primary operations during and outside regular working hours. MATERIAL AND METHODS: A total of 9,767 surgical procedures were identified from the Danish Fracture Database (DFDB). Procedures were grouped based on the surgeons' level of experience, extent of supervision, type (primary, planned secondary or reoperation), classification (AO Müller), and whether they were performed during or outside regular hours. RESULTS: Interns and junior residents combined performed 46% of all procedures. A total of 90% of surgeries by interns were performed under supervision, whereas 32% of operations by junior residents were unsupervised. Supervision was absent in 14-16% and 22-33% of the three most frequent primary procedures and reoperations when performed by interns and junior residents, respectively. The proportion of unsupervised procedures by junior residents grew from 30% during to 40% (p < 0.001) outside regular hours. CONCLUSION: Interns and junior residents together performed almost half of all fracture-related surgery. The extent of supervision was generally high; however, a third of the primary procedures performed by junior residents were unsupervised. The extent of unsupervised surgery performed by junior residents was significantly higher outside regular hours. FUNDING: not relevant. TRIAL REGISTRATION: The Danish Fracture Database ("Dansk Frakturdatabase") was approved by the Danish Data Protection Agency ID: 01321.