Incidence of complications among operative pediatric supracondylar humerus fractures using medial and lateral pins: a safe technique for percutaneous medial pin placement.

Cross-pinning of displaced pediatric supracondylar elbow fractures offers a superior stability construct. However, there is a reluctance to use this construct by closed means because of the risk of iatrogenic ulnar nerve injuries associated with percutaneous medial pin placement. This study describes a safe technique for closed reduction percutaneous with medial pin placement. This study reviewed the clinical charts of 232 pediatric patients who underwent closed reduction with cross-pinning of Gartland type II and III supracondylar fractures from 2000 to 2022 at a single institution. All surgeries were performed by the same attending surgeon at the same institution, with the same technique of medial pin placement. The inpatient and outpatient notes were used to record patient demographic information, fracture classification, and postoperative complications. A total of 232 pediatric patients [114 boys, 118 girls; mean age: 5.8 (range: 1-14) years] with Gartland type II (n = 97) and III (n = 135) supracondylar fractures were included in the study. There were a total of seven (3.02%) postoperative complications: four (1.7%) ulnar neuropathies, two (0.86%) pin site infections, and one (0.43%) anterior interosseous nerve palsy. All documented postoperative complications were resolved by the 3-month follow-up visit. There were no complications of deep infection, malunion, or nonunion. With the proper technique, closed reduction with percutaneous medial pin fixation of pediatric supracondylar fractures is safe and produces excellent postoperative outcomes. Level of Evidence: Level IV, case series.

Spontaneous Resolution of an Osteochondroma.

A 13-year-old girl presented with an apparent classic osteochondroma. Because she was skeletally immature, the decision was made to observe the lesion. She returned to the clinic at age 17 for unrelated reasons and was noted to no longer have the palpable mass. Magnetic resonance imaging confirmed resolution of the osteochondroma. The age range of this case fits with reported cases of childhood osteochondromas. The mechanism of resolution has been theorized to be incorporation of the lesion back into the bone during remodeling, fractures, or pseudoaneurysms. An initial period of observation is thus recommended with new patients.

Minimally Invasive SPML Surgery for Children with Cerebral Palsy: Program Development.

Improvements in surgical and rehabilitation care are critical to lessen the burden of cerebral palsy (CP), the most common cause of severe physical disability in childhood. The selective percutaneous myofascial lengthening (SPML) surgical procedure is a minimally invasive method designed to improve ambulation by lengthening contracted musculoskeletal tissues. Information on surgical procedures, efficacy, and safety of SPML for children with CP is lacking. Phase 1 of our research is a "proof-of-principle" study for multisite SPML to improve functional mobility of children with CP, and Phase 2 assesses safety, reoperation rates, and efficacy over time in subsequent patient series. Phase 1 was a repeated measurement case series study of 17 children (mean age 7.6 years). One physical therapist, blinded to the surgeon's measurements, measured bilateral knee and ankle motion before and after SPML procedures, using video recordings of a standardized gait path. Functional Mobility Scale (FMS) 5, 50, and 500 outcomes were taken pre- and postoperatively and via telephone follow-up. In Phase 2, multisite SPLM surgeries were implemented in larger successive cohorts from 2006 to 2017. Complications, reoperation rates, and efficacy were retrospectively analyzed. Phase 1 results showed improvement in the children's knee and ankle motion while ambulating and improved FMS 5, 50, and 500 outcomes postoperatively (mean, 6.3 months). At second follow-up (mean 33.3 months), FMS 500 scores continued improvement, while FMS 5 and FMS 50 scores maintained. During Phase 2, the complication rate was 2.4%, and reoperation rates (including reoperations due to maturation) were between 8% and 13%. Improvements to correct ankle equinus were recorded in 498 cases. In conclusion, in a specialized center, single-event, multilevel SPML surgeries of children with CP safely improved ambulatory knee and ankle angle motion and daily mobility outcomes. Future educational studies of training needs for surgeons new to the approach are needed.

Underestimation of fluoroscopic exposure among orthopedic residents.

OBJECTIVES: Concerns about radiation exposure for health care workers have increased in the last decade, along with the increased use of fluoroscopic imaging for surgical procedures. Recent literature suggests that surgeons with the least experience have higher exposure during surgery, and their perception of exposure may be lower. The purpose of this study was to examine the accuracy of orthopedic resident trainees' estimates of their exposure during fluoroscopy cases. MATERIALS AND METHODS: Orthopedic resident trainees were surveyed after participation in various fluoroscopic orthopedic surgeries and asked to estimate the number of fluoroscopy exposures used. Their answers were compared against the actual number of exposures retrieved from the fluoroscopy machine. The perceived number of exposures was then compared to the actual number taken for junior residents in training year 1, 2, or 3 versus senior residents in training year 4 or 5. RESULTS: Nineteen residents were surveyed, 13 of which were junior residents and six of which were senior residents. Of the 13 junior-level residents, total estimation was 441 exposures, versus 1411 actual exposures, an underestimation of over 69%. The six senior residents totaled 457 estimated exposures, compared to 645 actual exposures, for an underestimation of just under 30%. CONCLUSIONS: In this survey study at a single institution, junior-level residents greatly underestimated radiation exposure compared to senior-level residents. Trainees should be aware that they grossly underestimate their exposure levels during procedures, and residency programs should emphasize fluoroscopic training early.

Distal Femur Insufficiency Fracture in a Pediatric Patient: An Atypical Presentation of Osteogenesis Imperfecta: A Case Report.

CASE: We present an unusual case of a distal metaphyseal femur insufficiency fracture in an adolescent with a history of multiple low-energy appendicular fractures. A genetic workup was significant for a variant of unknown significance to the Col1A1 gene. CONCLUSIONS: To our knowledge, this is the first report of this collagen gene variant as a risk factor for multiple fractures. The case illustrates the presentation of this gene's phenotype and suggested medical management.

Surgical Procedures Needed to Eradicate Infection in Knee Septic Arthritis.

Septic arthritis of the knee is encountered on a regular basis by orthopedists and nonorthopedists. No established therapeutic algorithm exists for septic arthritis of the knee, and there is much variability in management. This study assessed the number of surgical procedures, arthroscopic or open, required to eradicate infection. The study was a retrospective analysis of 79 patients who were treated for septic knee arthritis from 1995 to 2011. Patients who were included in the study had native septic knee arthritis that had resolved with treatment consisting of irrigation and debridement, either open or arthroscopic. Logistic regression analysis was used to explore the relation between the interval between onset of symptoms and index surgery and the use of arthroscopy and the need for multiple procedures. Fifty-two patients met the inclusion criteria, and 53% were male, with average follow-up of 7.2 years (range, 1-16.2 years). Arthroscopic irrigation and debridement was performed in 70% of cases. On average, successful treatment required 1.3 procedures (SD, 0.6; range, 1-4 procedures). A significant relation (P=.012) was found between time from presentation to surgery and the need for multiple procedures. With arthroscopic irrigation and debridement, most patients with septic knee arthritis require only 1 surgical procedure to eradicate infection. The need for multiple procedures increases with time from onset of symptoms to surgery.

Ultrasound for Infants at Risk for Developmental Dysplasia of the Hip.

The best screening method for developmental dysplasia of the hip is controversial. Ultrasonography is sensitive, but cost-effectiveness may limit its use. This study assessed whether ultrasound screening would increase in effectiveness if targeted toward infants with established risk factors for developmental dysplasia of the hip and normal findings on physical examination. All ultrasound scans performed at the authors' institution from January 2007 through January 2011 to screen for developmental dysplasia of the hip were reviewed. Infants with risk factors for developmental dysplasia of the hip and normal findings on physical examination by orthopedic faculty or a pediatrician were selected. Of the 530 cases that were reviewed, 217 had risk factors for developmental dysplasia of the hip and normal findings on physical examination. Mean age of the 217 selected patients was 6.9 weeks. Of the patients, 83% were female, 77% had breech presentation, 30% were firstborn children, 13% had intrauterine packaging abnormalities, and 3% had a family history of developmental dysplasia of the hip. Of the 217 infants, 44 had 1 risk factor, 121 had 2 risk factors, 46 had 3 risk factors, and 6 had 4 risk factors. Dynamic ultrasound evaluation showed instability in 17 patients, for a 7.8% incidence of developmental dysplasia of the hip. All 17 patients were treated with a Pavlik harness. The results suggested that selective ultrasound screening may be effective in infants with risk factors and normal findings on physical examination. Selective ultrasound screening changed treatment management in almost 8% of patients and clinical follow-up in 6.5%. Analysis of the cost-effectiveness of screening is needed.

Prevalence of stump overgrowth in pediatric burn patient amputations.

BACKGROUND: Pediatric patients sometimes require amputation as part of their life-saving burn care. Bone overgrowth is known to occur in these amputation patients at rates of 4% to 43% depending on the study. METHODS: We conducted a retrospective study of all patients who underwent amputation at a children's burn center for a 45-year span. There were 18,880 burn patients during this time frame and 149 pediatric patients with amputation who survived long-term were studied. Burn types included flame, electrical, scald, thermal, and combination types in order of prevalence. We studied bone overgrowth as defined as those children requiring revision surgery. RESULTS: One hundred forty-nine patients underwent a total of 259 amputations. The average age at the time of amputation was 7.48 years. Stump overgrowth occurred in 15 patients (10.1%) or 15 of the 259 amputations (5.8%) overall. Bone overgrowth occurred in 11 of 104 flame burn patients (10.6%), 3 of 32 electrical burns (9.4%), and 1 of 9 scald burns (11.1%). Many patients had multiple amputations so the incidence for amputations was 6.1% (11 of 179) for flame, 5.4% (3 of 56) for electrical, and 5.9% (1 of 17) for scald burns. The mean time to overgrowth from primary amputation to revision surgery was 41.5 months. Overgrowth was more common in the lower extremities (17 of 104, or 16.3%) than in the upper extremities (3 of 153, or 2%). CONCLUSIONS: Bony overgrowth after amputation in pediatric burn patients occurs at a rate of 10.1% of patients or 5.8% of amputations. Younger children are more likely to have overgrowth. The type of burn does not influence overgrowth and lower extremity amputations are more likely to show overgrowth than upper extremities. LEVEL OF EVIDENCE: Level IV, case series.

Plaster and synthetic cast temperatures in a clinical setting: an in vivo study.

Previous studies have reported thermal injuries with thick cast materials and warm dip water temperatures, often much higher than is clinically applicable. The goal of this study was to assess the temperature produced in vivo by current casting techniques and materials. The study was done using clinically applicable materials and water temperatures. A single volunteer was used to test skin temperatures produced with various casting techniques. We tested several types of fiberglass and plaster of 5 or 10 layers, used soft roll of 1 or 3 layers, and used dip water temperatures of 30 °C and 40 °C. We tested 2 plaster types: Johnson & Johnson Specialist Fast Set and Specialist Extra Fast Set (New Brunswick, New Jersey). Fiberglass tested included 3M Scotchcast Poly Casting Tape and Scotchcast Plus (St Paul, Minnesota), Royce Medical Techform (Camarrillo, California), and DeBusk Classic Synthetic Tape (Powell, Tennessee). The highest temperature reached using 30 °C water temperature was 39 °C with 10 layers of 3M Scotchcast fiberglass and 1 layer of soft roll. The highest temperature reached with 40 °C water was 39.5 °C, which was reached twice: once with Johnson & Johnson Fast Set Plaster with 5 layers of plaster and 3 layers of soft roll, and once with DeBusk Classic Synthetic Casting Tape of 10 layers with 1 layer of soft roll. Under the clinically applicable conditions described in this study, using the materials we tested and with a normal vascular supply, it is unlikely that temperatures high enough to cause a burn will be produced. We caution that good clinical judgment is advised if a patient reports a cast is too hot.

Carpal coalition with radioscaphoid synostosis and hypoplastic thumb.

Carpal coalition is an anomaly that is usually discovered as an incidental finding on roentgenograms. The most common site is between the lunate and the triquetrum, though fusion of almost every combination of carpal bones has been reported. Carpal coalition can be isolated but has also been associated with numerous congenital malformation syndromes. In this article, we report the case of a 12-year-old boy with left-sided asymptomatic fusion of the trapezoid and trapezium, fusion of the radius and scaphoid, and hypoplasia of the thumb.

A t(1;9)(q10;q10) translocation with additional 6q23 and 9q22 rearrangements in a case of chondromyxoid fibroma.

Chondromyxoid fibroma (CMF) is a rare cartilaginous tumor of bone. It typically presents in the long tubular bones and to a lesser extent in the small bones of the hands and feet of young adults. To date, several cytogenetic abnormalities have been described in association with CMF. We studied a phalangeal CMF from a 13-year-old female by cytogenetic methods. We found a novel unbalanced translocation between the long arms of chromosomes 1 and 9, resulting in loss of 1p. In addition, rearrangements involving the 6q23 and 9q22 regions were also observed. To our knowledge, this is the first report in the literature describing this novel chromosomal translocation in CMF.

Combined medial and lateral condyle elbow fractures in a 3-year-old boy.

We present a rare elbow fracture pattern in a 3-year-old boy who sustained concomitant medial and lateral elbow condyle fractures. The lateral condyle fracture was not initially appreciated on standard anteroposterior and lateral radiographs and was demonstrated best on oblique view. The patient underwent open reduction and internal fixation of both medial and lateral condyles that resulted in uneventful healing. This underlines the importance of obtaining oblique views of the elbow when diagnosing a complex elbow fracture in the skeletally immature patient.

Familial tumoral calcinosis: a forty-year follow-up on one family.

BACKGROUND: Familial tumoral calcinosis is a rare autosomal recessive disorder that was first described well in a report on four patients from one family in 1969. The disease leads to periarticular ectopic calcifications. The original report described patients from black, healthy, unrelated parents with sixteen children, seven of whom had the disease. METHODS: On the basis of retrospective chart reviews and interviews with surviving family members, we describe the long-term follow-up of this one family, encompassing as long as forty years. Of the sixteen siblings, seven had tumoral calcinosis. RESULTS: All seven affected children had hyperphosphatemia. There were two subsequent generations comprising thirteen children and seven grandchildren with no instances of tumoral calcinosis. The seven affected patients were followed for as many as forty years and underwent an average of twenty-one operations (range, four to thirty-six operations) for the treatment of calcified lesions. The genetic defect has been identified as the GALNT3 gene, thus leading to the hyperphosphatemic form of the disease. Although two of the patients had died by the time of the present study, the remaining five provided accounts of the disease course, the response to surgery and to medical therapy, and the effect of therapy on their lives. Some members had relatively few lesions and surgical procedures (as few as four), whereas others had an unrelenting course of lesions, recurrences, and surgical procedures (as many as thirty-six, with numerous other procedures). Three patients had multiyear periods with few symptoms--one for seven years, one for twelve years, and one for fifteen years. No effective medical therapy was found to control the lesions, and operations were associated with a high recurrence rate. CONCLUSIONS: Familial tumoral calcinosis has a varied natural history; some patients have an unrelenting course, while others may experience quiescent periods. The GALNT3 gene is responsible for the hyperphosphatemic form as seen in this family. Molecular testing may be of benefit to members of affected families, and future studies may help to explain the phenotypic variability among affected individuals. No medical or surgical treatment plan seemed to be effective for controlling the lesions in this family.

Biomechanical study of flexible intramedullary nails.

BACKGROUND: Flexible intramedullary (IM) nailing is considered a safe, minimally invasive fixation technique with relatively low complication rates for long-bone fractures in the pediatric population. At our institution, questions have arisen about stability of fixation based on the distance of the nail past the fracture site. Clinically, this question arises with proximal or distal fractures and when the nail is unable to be passed to the desired distance past the fracture site. The purpose of our study was to compare biomechanical resistance with bending forces for fixation constructs whose IM nails are at differing distances beyond the fracture site in different bones. METHODS: This study tested matched pairs of canine radii, ulnas, and tibias in 4-point bending and compared the biomechanical properties of length of nail fixation past the fracture site in relation to bone diameter. RESULTS: Fixations of 1 or 2 diameters past the osteotomy yielded gross instability. There was no difference found in bending failure force, displacement, stiffness, or energy when comparing 3 versus 5 diameters of fixation past the fracture site. CONCLUSIONS: Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more beyond the fracture site, the length does not significantly affect the biomechanical properties of the construct. CLINICAL RELEVANCE: Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more past the fracture site, the length of the nail does not greatly affect the biomechanical properties of the construct. This knowledge may be helpful in clinical scenarios where there is uncertainty about the expected strength of a shorter fixation. Examples include when the nail cannot be passed completely to the distal metaphysis and in proximal or distal long-bone fractures. Further clinical studies are needed to determine implications in a patient setting.

The use of ultrasound to determine timing of Pavlik harness discontinuation in treatment of developmental dysplasia of the hip.

The timing of Pavlik harness removal in patients with developmental dysplasia of the hip is typically determined by clinical examination. Ultrasound is considered more sensitive than clinical examination in diagnosis of instability of the hip, but it is not routinely used in cases of developmental dysplasia of the hip, especially when determining the timing of Pavlik harness removal. The purpose of this study is to investigate if ultrasound examination is more effective than clinical examination alone in determining completion of Pavlik harness treatment. Fifty consecutive infants with developmental dysplasia of the hip were given both a clinical examination and dynamic ultrasound examination to determine if Pavlik harness treatment could be discontinued. A pediatric orthopedist conducted the physical examinations. Both a radiologist and a pediatric orthopedist interpreted the ultrasounds. Cost estimates for ultrasound and operative procedures were obtained at our institution and compared. The average age at the time of Pavlik harness placement was 5.3 days, and the average age at the time of ultrasound was 54.3 days. There were 35 females and 15 males and 31 left hips, 4 right hips, and 15 bilateral hips. All 50 patient hips were deemed clinically stable prior to obtaining an ultrasound. The ultrasound interpretations by a radiologist and pediatric orthopedist were in agreement in all cases. In one case, the ultrasound results did not correlate with results of the clinical examination. In that one case, the hip was clinically stable, but dynamic ultrasound revealed that the hip was located, but dislocatable. The Pavlik harness was reapplied to the patient for an additional 42 days. At 1-year follow-up the hip is stable and developing normally as determined by radiographs. The cost comparison revealed that the cost of 50 ultrasounds is less than the cost of a single operative procedure. The use of ultrasound to determine the timing of Pavlik harness cessation is justified from both a financial and a patient outcome perspective in this small study. Larger studies are needed before ultrasound examination used to help determine Pavlik cessation is considered standard of care.

The orthopedic and renal manifestations of idiopathic carpal tarsal osteolysis.

Idiopathic carpal tarsal osteolysis (ICTO) is a rare congenital disorder that results in the destruction and resorption of bone, leading to severe functional deficits and cosmetic deformities. This report includes a literature review describing the orthopedic and renal manifestations of ICTO. An additional case report of ICTO with atypical features is included.

Outcomes assessment of pediatric both-bone forearm fractures treated operatively.

This study assessed the outcome of pediatric both-bone forearm fractures treated with operative intervention. A retrospective review was conducted of 31 patients treated over a 40-month period. Fifteen patients were treated with flexible intramedullary nailing and 16 treated with open reduction and internal fixation. Average patient age was 11 years (range: 3.8-17.9 years). Operative indications included 2 open fractures and 29 fractures with unacceptable reductions. The intramedullary nailing group had 14 excellent results and 1 good result. The open reduction internal fixation group had 15 excellent results and 1 good result. Overall, 29 (93.5%) of 31 patients had excellent results. Two minor complications occurred in the intramedullary nailing group and none in the open reduction internal fixation group. Although operative intervention in pediatric both-bone forearm fractures is rarely indicated, when necessary, good results can be expected.

Incidence of pin track infections in children's fractures treated with Kirschner wire fixation.

Smooth Kirschner wires (K-wires) are frequently used in pediatric orthopaedics; however, the infection rate associated with these devices is not known. A retrospective study on infection rates in pediatric patients who had fractures treated with percutaneous smooth K-wire fixation was performed. A total of 202 patients with an average age of 9.7 years were included in the study. Upper extremity fractures made up 93% of the cases. The overall infection rate was 7.9%. The classification system of Green was used to describe major and minor infections. There were 16 infections noted; 12 (5.9%) of these were minor, and 4 (2%) were major. Infection rates did not correlate with length of fixation. There was also no correlation of increased infection rates with open fractures or fractures that required open reduction. The infection rates associated with the use of smooth K-wires in pediatric fracture patients is low. The major infection rate is only 2% and does not correlate to length of fixation or type of fracture.

Proximal femoral neck penetration after flexible intramedullary nailing for pediatric femur fractures: a rare complication.

Flexible intramedullary nailing is a common method used to treat pediatric femur fractures. Complication rates can be high, but most complications are considered minor and do not result in additional unplanned surgeries. Proximal nail penetration is a complication that has only been described once before. The penetration may be asymptomatic, but is still best to be avoided. Two cases of proximal nail penetration of the femoral neck region during nail insertion are presented. A review of the literature with regard to complications and suggestions for avoidance of proximal nail penetration is offered.

Biomechanical comparison of flexible intramedullary nailing versus crossed Kirschner wire fixation in a canine model of pediatric forearm fractures.

This study compares the biomechanical properties of crossed Kirschner wires with those of flexible intramedullary nails in a canine model. The Kirschner wire groups had greater anteroposterior, lateral, and torsional stiffness and force to failure rates in most of the bones tested. Bones fixated with flexible intramedullary nails could bend and recoil during failure testing. The bones fixated with Kirschner wires failed at smaller levels of displacement and frequently had hardware cut-out during failure testing. Flexible intramedullary nails have more recoil and do not induce new fracture lines, which may explain their clinical superiority to Kirschner wires despite providing less rigid fixation.