Pediatric Elbow Dislocations and Associated Fractures.

The objective was to evaluate pediatric patients with acute elbow dislocation and/or associated fracture to determine which were indicated for surgical intervention, using a single institution, Institutional Review Board (IRB) approved retrospective review of patients who presented to the Emergency Department (ED) with an acute elbow dislocation. Inclusion criteria were age ≤ 18 years, acute elbow dislocation injury, and appropriate imaging. A total of 117 patients were included 37 had a simple elbow dislocation, 80 had an associated fracture (medial epicondyle 59, lateral condyle 9, radial head/neck 7, other 5). A total of 62% (73/117) were male. The average age was 10.3 years (range 4-17). Mechanisms of injury included: falls from height/playground equipment (46), trampoline (14), and sports (57). All 37 patients with a simple elbow dislocation were successfully treated with closed reduction. Of the 80 patients with an associated fracture, 30 (38%) went on to open reduction internal fixation (ORIF). A total of 59 patients had an associated medial epicondyle fracture; 24 (41%) of whom went on to ORIF. Nine patients had an associated lateral condyle fracture, five (56%) of whom went on to ORIF. Patients with a simple elbow dislocation can be successfully treated with a closed reduction in the ED. However, 30/80 patients with an associated fracture (medial epicondyle, lateral condyle, or radial neck) required operative management.

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.

The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study With Treatment Algorithm.

BACKGROUND: Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. METHODS: A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. RESULTS: Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). CONCLUSION: This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. LEVEL OF EVIDENCE: Level IV.

Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation.

BACKGROUND: Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds. METHODS: An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room. RESULTS: A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention. CONCLUSIONS: Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Ascl3 marks adult progenitor cells of the mouse salivary gland.

The Ascl3 transcription factor marks a subset of salivary gland duct cells present in the three major salivary glands of the mouse. In vivo, these cells generate both duct and secretory acinar cell descendants. Here, we have analyzed whether Ascl3-expressing cells retain this multipotent lineage potential in adult glands. Cells isolated from mouse salivary glands were cultured in vitro as non-adherent spheres. Lineage tracing of the Ascl3-expressing cells within the spheres demonstrates that Ascl3+ cells isolated from adult glands remain multipotent, generating both duct and acinar cell types in vitro. Furthermore, we demonstrate that the progenitor cells characterized by Keratin 5 expression are an independent population from Ascl3+ progenitor cells. We conclude that the Ascl3+ cells are intermediate lineage-restricted progenitor cells of the adult salivary glands.