Pediatric Musculoskeletal Trauma: Upper Limb.

Pediatric upper extremity injuries, acute and chronic due to overuse, are commonly encountered in the clinical setting. However, interpretation of imaging studies is often challenging in pediatric patients because of changing postnatal skeletal development and the broad spectrum of pathology that can potentially occur. This article discusses normal skeletal development and the pathomechanics of skeletal injuries in pediatric patients. It also outlines a framework for imaging as it pertains to the pediatric upper extremity, with specific emphasis on acute and chronic injuries to the shoulder, elbow, forearm, and wrist.

Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis.

BACKGROUND: Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. METHODS: Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. RESULTS: Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration. CONCLUSIONS: Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Are S1 Screws a Useful Adjunct to Iliac Screws in Long Fusions to the Sacrum in Cerebral Palsy?

STUDY DESIGN: Multicenter prospective database review of patients with cerebral palsy (CP) and spinal deformity. OBJECTIVE: To determine if the type of distal fixation is associated with improved correction of coronal deformity or pelvic obliquity (PO) at 2 years in long posterior fusions to the sacrum. SUMMARY OF BACKGROUND DATA: Multiple techniques are utilized for distal fixation in patients with CP. Although there is emerging evidence that the augmentation of iliac screws with S1 screws may be beneficial, this remains controversial. METHODS: A prospective, multicenter database was used to identify patients with CP who underwent long posterior fusions to the sacrum. Eighty-eight patients were included, 52 with iliac screws (I) and 36 with iliac and S1 screws (IS) for distal fixation. Preoperative, first erect, and 2-year follow-up radiographs and complications were analyzed. Statistical analysis was performed using ANOVA and repeated measures ANOVA with significance set at P < 0.05. RESULTS: Scoliosis was the primary deformity in greater than 90% of patients in both groups (P=0.84). Preoperative coronal deformity was similar (I = 83°, IS = 87°, P = 0.49), but correction was better with the use of S1 screws on the first erect radiograph and at 2 years (I = 35°, IS = 22°, P = 0.001), reflecting correction of 58% and 74% for iliac and iliac-S1 screws, respectively (P < 0.001). Preoperative PO was similar (I = 29°, IS = 30°, P = 0.71) and was noted to improve more in the iliac-S1 group by 2 years (I = 11°, IS = 5°, P = 0.004), representing correction of 60% and 77% for the iliac and iliac-S1 groups, respectively (P = 0.018). There was no difference in the rate of major (P = 0.27) or minor (P = 0.65) complications in either group. CONCLUSION: Bilateral S1 and iliac screws are associated with improved spinal deformity and PO correction at 2 years in the CP population. Two points of distal fixation, S1, and ilium should be considered for this population. LEVEL OF EVIDENCE: 3.

Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction.

BACKGROUND: Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy. METHODS: A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed. RESULTS: Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92). CONCLUSIONS: Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities. LEVEL OF EVIDENCE: Level IV, case series.

"Ilizarov" external fixation: what the radiologist needs to know.

Circular external fixation, including the Ilizarov method, is a complex and often long-term treatment used for various orthopedic conditions. Due to the complexity of the hardware, frequent postoperative complications, and the potential for significant radiographic changes between visits, it is important for the radiologist to have a basic understanding of ring fixators. This publication reviews indications for external fixation versus internal fixation and whether to use a circular or uniplanar construct if external fixation is elected. Indications for and characteristics of static circular frames, intercalary and non-intercalary transport frames, and deformity circular frames will also be discussed. While general similarities exist between frame types, each has unique components of which the radiologist must be aware. An emphasis is placed on the important features and complications that arise during treatment.

The biomechanics of guided growth: does screw size, plate size, or screw configuration matter?

Guided growth with the eight-plate is a commonly used technique to correct angular limb deformities in children. However, the optimal combination of plate size, screw size, and screw configuration has not been determined. Using osteotomized femoral sawbones and a rail frame, we developed a growth model to examine the effect of these variables at 6-month, 12-month, and 18-month growth increments. The mean annual coronal plane change was 11.3°. Screw size and plate size were not associated with the rate of angular correction. Screw configuration was important, with parallel screws resulting in optimal correction at all time points compared with divergent screws (P<0.05).

Factors influencing lymph node recovery from the operative specimen after gastrectomy for gastric adenocarcinoma.

BACKGROUND: Regional lymph node metastases are an important predictor of survival for patients with resectable adenocarcinoma of the stomach. Currently, the number of lymph nodes examined is frequently less than requirements for accurate staging. Clinical factors associated with lymph node recovery are understood poorly. METHODS: We performed a retrospective chart review of 99 consecutive patients who underwent gastrectomy for gastric adenocarcinoma distal to the gastroesophageal junction to determine clinical variables associated lymph node recovery. RESULTS: Ninety-nine patients underwent gastrectomy for gastric adenocarcinoma at our two hospitals. More than 15 lymph nodes were examined in 64% of specimens. Univariate analysis showed an association between the number of lymph nodes recovered and the number of positive nodes, lymphadenectomy extent, hospital, surgeon, and pathology technician (p < 0.001). Multivariate analysis identified the pathology technician as the most important healthcare-related variable contributing to the variation of lymph node recovery, using fixed- (p < 0.001) and random-effects models. CONCLUSIONS: This study suggests that the pathology technician is an important healthcare-related factor influencing lymph node recovery after gastrectomy. In identifying potential areas benefiting from a systems improvements approach, focus on the technical aspects of specimen processing may be of benefit in maximizing the number of lymph nodes recovered.

Ultrasound-based transient elastography for the detection of hepatic fibrosis: systematic review and meta-analysis.

BACKGROUND & AIMS: Ultrasound-based transient elastography is a promising noninvasive alternative to liver biopsy for detecting hepatic fibrosis. However, its overall test performance in various settings remains unknown. The aims of this study were to perform a systematic review and meta-analysis of diagnostic accuracy studies comparing ultrasound-based transient elastography with liver biopsy for hepatic fibrosis. METHODS: Electronic and manual bibliographic searches to identify potential studies were performed. Selection of studies was based on reported accuracy of ultrasound-based transient elastography compared with liver biopsy. Data extraction was performed independently by 2 reviewers. Meta-analysis combined the sensitivities, specificities, and likelihood ratios of individual studies. Extent and reasons for heterogeneity were assessed. RESULTS: Nine studies in full publication were identified. For patients with stage IV fibrosis (cirrhosis), the pooled estimates for sensitivity were 87% (95% confidence interval [CI], 84%-90%), specificity 91% (95% CI, 89%-92%), positive likelihood ratio 11.7 (95% CI, 7.9-17.1), and negative likelihood ratio 0.14 (95% CI, 0.10-0.20). Among 7 investigations reporting patients with stages II-IV fibrosis, the pooled estimates for sensitivity were 70% (95% CI, 67%-73%), specificity 84% (95% CI, 80%-88%), positive likelihood ratio 4.2 (95% CI, 2.4-7.2), and negative likelihood ratio 0.31 (95% CI, 0.23-0.43). Diagnostic threshold (or cut-off value) bias was identified as an important cause of heterogeneity for pooled results in both patient groups. CONCLUSIONS: Ultrasound-based transient elastography appears to be a clinically useful test for detecting cirrhosis.

IL-10 diminishes CTLA-4 expression on islet-resident T cells and sustains their activation rather than tolerance.

IL-10, a powerful anti-Th1 cytokine, has shown paradoxical effects against diabetes. The mechanism underlying such variable function remains largely undefined. An approach for controlled mobilization of endogenous IL-10 was applied to the NOD mouse and indicated that IL-10 encounter with diabetogenic T cells within the islets sustains activation, while encounter occurring peripheral to the islets induces tolerance. Insulin beta-chain (INSbeta) 9-23 peptide was expressed on an Ig, and the aggregated (agg) form of the resulting Ig-INSbeta triggered IL-10 production by APCs, and expanded IL-10-producing T regulatory cells. Consequently, agg Ig-INSbeta delayed diabetes effectively in young NOD mice whose pathogenic T cells remain peripheral to the islets. However, agg Ig-INSbeta was unable to suppress the disease in 10-wk-old insulitis-positive animals whose diabetogenic T cells have populated the islets. This is not due to irreversibility of the disease because soluble Ig-INSbeta did delay diabetes in these older mice. Evidence is provided indicating that upon migration to the islet, T cells were activated and up-regulated CTLA-4 expression. IL-10, however, reverses such up-regulation, abolishing CTLA-4-inhibitory functions and sustaining activation of the islet T lymphocytes. Therefore, IL-10 supports T cell tolerance in the periphery, but its interplay with CTLA-4 sustains activation within the islets. As a result, IL-10 displays opposite functions against diabetes in young vs older insulitis-positive mice.

A sudden decline in active membrane-bound TGF-beta impairs both T regulatory cell function and protection against autoimmune diabetes.

Autoimmunity presumably manifests as a consequence of a shortfall in the maintenance of peripheral tolerance by CD4(+)CD25(+) T regulatory cells (Tregs). However, the mechanism underlying the functional impairment of Tregs remains largely undefined. In this study a glutamic acid decarboxylase (GAD) diabetogenic epitope was expressed on an Ig to enhance tolerogenic function, and the resulting Ig-GAD expanded Tregs in both young and older insulitis-positive, nonobese diabetic (NOD) mice, but delayed autoimmune diabetes only in the former. Interestingly, Tregs induced at 4 wk of age had significant active membrane-bound TGF-beta (mTGF-beta) and sustained protection against diabetes, whereas Tregs expanded during insulitis had minimal mTGF-beta and could not protect against diabetes. The Tregs probably operate suppressive function through mTGF-beta, because Ab blockade of mTGF-beta nullifies protection against diabetes. Surprisingly, young Tregs that modulated pathogenic T cells maintained stable frequency over time in the protected animals, but decreased their mTGF-beta at the age of 8 wk. More strikingly, these 8-wk-old mTGF-beta-negative Tregs, which were previously protective, became unable to confer resistance against diabetes. Thus, a developmental decline in active mTGF-beta nullifies Treg function, leading to a break in tolerance and the onset of diabetes.