Olecranon fractures in children and adolescents: outcomes based on fracture fixation.

PURPOSE: Open reduction and internal fixation with a tension band construct is the standard treatment for displaced transverse intra-articular olecranon fractures. The purpose of this study is to describe the outcomes of tension band fixation of olecranon fractures in children, specifically assessing the need for revision fixation and hardware removal. METHODS: Patients less than 18 years of age diagnosed with a displaced transverse intra-articular olecranon fracture and treated with tension band fixation between 2008 and 2017 were retrospectively enrolled. Operative treatment was with tension band wire (TBW) or tension band suture (TBS) constructs. RESULTS: A total of 46 patients, 36 male and ten female with a mean age of 12.3 years (6 to 17), were included. Surgical fixation was with TBW in 17 patients and TBS in 29 patients. Revision fixation due to failure and fracture displacement was required in 6% of the TBW group and 14% of the TBS group (p = 0.19). The patients who required revision fixation in the TBS group were older (14.7 years versus 11.6 years, p = 0.05) and heavier (70.5 kg versus 48.5 kg, p = 0.05) than those in the same group who did not require revision fixation. CONCLUSION: Paediatric olecranon fractures treated with TBW or TBS fixation unite in the majority of patients with similar need for hardware removal due to prominence and/or pain between fixation techniques. In a select group of older patients weighing greater than 50 kg, TBS constructs demonstrate increased failure rates, requiring revision fixation, and should be avoided in this population group. LEVEL OF EVIDENCE: IV.

Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents.

PURPOSE: Superiority of non-operative versus operative treatment of clavicle shaft fractures remains unclear. We aimed to assess shoulder function in adolescents following shortened clavicle fracture and compare operative versus non-operative treatment. METHODS: Patients aged 12 to 18 years at the time of fracture and minimum 1.5 years post injury were identified for this institutional review board (IRB)-approved study. For this retrospective cohort study, patients were frequency-matched for age, gender, shortening of the clavicle fracture and activity level. The dominant arm was controlled in the statistical model. Initial radiographs were used to measure clavicle shortening. At follow-up, isokinetic testing of both shoulders was performed in flexion, external rotation and the plane of scapular motion. Maximum number of isotonic repetitions and average isometric torque were recorded, as were ASES and DASH scores. Data were analysed comparing non-operative and operative groups and involved and uninvolved shoulders. RESULTS: Twenty patients were recruited (18 male, 2 female), with ten in each group. Median clavicle shortening was 17.5 mm (11.4 to 23.6). There was no statistical difference in average ASES (100 vs 99; p = 0.84) or DASH (0.0 vs 1.7; p = 0.08) between non-operative and operative groups, respectively. Results of isokinetic testing comparison between non-operative and operative groups showed no statistical difference for any individual association, controlling for the dominant arm. Among the non-operative group, the involved arm had decreased functional measures compared with the uninvolved arm on all measures, when controlling for dominant arm, and there was increased variability of the functional estimate. CONCLUSIONS: The increased variability in functional measures for the non-operative group suggests some patients may have dysfunction.

Coaxial portals for posterior ankle arthroscopy: An anatomic study with clinical correlation on 29 patients.

PURPOSE: The authors performed a cadaveric study on 10 ankles and retrospectively reviewed 29 arthroscopic synovectomies to determine the trajectory, minimal safe distances, and complications using a new approach for posterior ankle arthroscopy. TYPE OF STUDY: Anatomic study and case series. MATERIALS AND METHODS: A posterolateral portal was established immediately posterior to the peroneal tendon sheath. While staying within the posterior ankle capsule, an inside-out technique was then used to establish the posteromedial portal directly behind the medial malleolus adjacent to the posterior tibial tendon. The cadaveric ankles were frozen, sectioned, and photographed to measure the proximity of neurovascular structures to these coaxial portals. From 1988 to 1994, arthroscopic synovectomy was performed on 23 patients (29 ankles) with hemophilia using these modified portals. RESULTS: Results of the anatomic study showed that the posterior tibial nerve and posterior tibial artery were located a mean distance of 5.7 mm (SEM, 0.6 mm) and 6.4 mm (SEM, 0.7 mm) from the edge of the cannula, respectively. Neither penetration nor contact of nerve or vessel was observed at either posterior portal. In the 29 clinical cases, posterior capsular synovectomy was achieved arthroscopically with no detectable complications at an average 45-month follow-up. CONCLUSIONS: Our anatomic data show that the coaxial portals described here are essentially equidistant to the neurovascular structures compared with conventional portals. Our clinical results suggest that his technique for posteromedial and posterolateral portals is safe, effective, and reproducible.

Intramedullary fixation of unstable forearm fractures in children.

Although most forearm fractures in children are appropriately treated with closed reduction and cast immobilization, certain unstable fractures of the radius and ulna are best treated operatively. We present our technique of using flexible intramedullary fixation to stabilize these fractures. Retrograde fixation of the radius is obtained with a 5/64th or 3/32nd Steinmann pin, and stabilization of the ulna is achieved with a 1/8th inch Rush rod. Complications from this technique are few. The rods are usually removed after fracture union to avoid painful hardware.

Stingers, the Torg ratio, and the cervical spine.

We prospectively determined the risk of initial stinger experience in a group of college football players while considering the presence of cervical canal stenosis and each player's position, playing time, and body type. Prospective analysis revealed a 7.7% incidence of initial stinger experience. The average Torg ratio for all players was 0.924 +/- 0.122, with the seventh cervical level being the narrowest. Initial stinger experience depended on position played and body type. The Torg ratio did not influence initial stinger occurrence. Players who experienced multiple stingers, however, had significantly smaller Torg ratios than players experiencing only one stinger (0.75 versus 0.87). A Torg ratio of 0.70 may be a more statistically and clinically appropriate threshold for determining significant cervical stenosis and advising collegiate athletes of their risk of experiencing recurrent stingers.

Supracondylar humerus fractures. Current trends and controversies.

Supracondylar fractures of the humerus are one of the largest sources of serious problems and treatment controversy in childhood fractures. Improved understanding of the injuries to both the bone and soft tissue has contributed to improved outcomes. These fractures remain challenging to even the most experienced physician. This article reviews the pertinent biomechanics, outlines treatment principles, illustrates our reduction and percutaneous pin fixation technique, and highlights the major areas of controversy.

Meniscal injuries in children and adolescents.

Meniscal tears occur in children and adolescents even though they have open physeal plates. Appropriate clinical evaluation and use of imaging studies is important because making a diagnosis can be difficult. Meniscectomy and partial meniscectomy are associated with long-term morbidity. Repair of meniscal tears in youths is the preferred treatment.

Pitfalls of the lateral retinacular release.

The treatment of patellofemoral pain is fraught with pitfalls; however, most of these pitfalls can be recognized. Results of LRR in appropriate circumstances are reasonably good, and the complications are acceptably low. Risk factors for poor results are identifiable, and avoidance of the common complications are necessary to achieve reliable results. Cases of persistent pain after LRR must be approached in a thorough and orderly fashion. There should be clear indications and cautious expectations for the success of subsequent procedures.

Slipped capital femoral epiphysis.

SCFE is one of the most potentially damaging conditions of the adolescent hip. The onset may be associated with minor trauma but is often insidious and may present as vague thigh or knee pain. The lateral radiograph is the most sensitive view for detection of a low-grade slip. The contralateral hip must be examined carefully as there may be bilateral disease with the pain and disability of the presenting side masking the symptoms of less involved hip. SCFE is occasionally associated with other metabolic and endocrinologic disease, and these should be screened for in the history and physical examination. Once a slip begins, the hip remains at jeopardy for acute progression until the physeal plate closes. We recommend immediate surgical stabilization and prefer a cannulated screw system. Proper technique is critical to safe and reliable surgery. The most common complications, AVN and chondrolysis, are often related to technical errors and should be minimized with attention to detail.

Alterations in influenza virus pulmonary pathology induced by diethyl ether, halothane, enflurane, and pentobarbital anesthesia in mice.

Three-week-old CD-1 mice infected with the PR-8 (mouse-adapted) strain of influenza virus while exposed to enflurane demonstrated a decrease in virus titers from the lungs of infected animals, less abnormality of lung histology, and an increase in survival in animals as compared with those receiving the other anesthetics tested. Greater than 90% mortality occurred in groups of mice which inhaled aerosolized virus and received no anesthesia, pentobarbital, diethyl ether, or halothane anesthesia 96 h following infection. Infected mice anesthetized with enflurane 96 h post-infection had significantly lower mortality rate (68%) when compared with the other groups. Halothane-anesthetized mice receiving intranasal influenza virus during anesthesia demonstrated increased survival and a delay in the mean day of death when compared with animals receiving either diethyl ether of pentobarbital anesthesia. Animals receiving enflurane during virus inoculation had an even lower mortality rate and a later mean day of death when compared with infected animals receiving day of the other three anesthetics. Examination of lungs from animals infected during anesthesia demonstrated influenza virus titers significantly less in the animals that received enflurane anesthesia when compared with the other groups. Histologic sections of lungs revealed extensive spread of the disease process into the alveoli and interstitium of the lungs of animals infected while receiving pentobarbital or diethyl ether anesthesia. Animals infected during halothane demonstrated pathologic characteristics similar to pentobarbital- and diethyl-ether-treated groups; however, the changes were not as extensive. Mice infected during exposure to enflurane revealed only a mild bronchopneumonia.