Early Ultrasound Follow-Up of Extension-Type Supracondylar Fractures Treated by the Collar-and-Cuff (Blount) Technique.

BACKGROUND: Extension-type supracondylar fractures can be treated with external immobilization, with the elbow flexed 100°. However, this technique requires early evaluation by true lateral x-ray of the elbow to detect secondary fracture displacement. QUESTIONS/PURPOSE: The purpose of this work is to evaluate whether ultrasound imaging is suitable for demonstrating initial reduction of supracondylar fractures and early secondary displacement of the fracture. METHODS: Fourteen patients aged 3 to 7 years (mean, 4.8 years) were treated by closed reduction under general anesthesia and immobilization with a collar and cuff. All patients had early postoperative x-rays and ultrasonography on day 1, as well as day 8 x-rays and ultrasonography. Ultrasonograms were performed by an experienced senior radiologist. RESULTS: In all cases, a complete reduction was confirmed at initial follow-up on both sonogram and intraoperative fluoroscopy. In 13 of 14 cases, no secondary displacement of the fracture was noted at day 8 on either ultrasonography or x-ray images. In 1 case, a secondary displacement was noted at day 8 on ultrasonography and confirmed by the lateral x-ray. CONCLUSIONS: Our study found a complete agreement assessing the quality of intraoperative reduction of supracondylar fractures by radiographs and ultrasonography. These results confirm that ultrasound imaging is suitable for demonstrating secondary displacements of supracondylar fractures in children. We postulate that in Gartland types II and III fractures treated by Blount procedure, a negative ultrasound result at day 8 follow-up may reduce the need for further radiographs. However, in any doubtful situation, the need for conventional radiographs remains. LEVEL OF EVIDENCE: Diagnostic study, level II.

The Indian Basket Trick: a case of delayed paraplegia with complete recovery, caused by misplaced thoracic pedicle screw.

INTRODUCTION: Pedicle screw fixation allows purchase of all three spinal columns without encroaching into the spinal canal improving fracture fixation, as well as deformity correction. Fortunately, neurologic injury associated with pedicle screw malposition is rare. CASE PRESENTATION: A 19-year-old boy was surgically treated for severe right thoracic scoliosis associated with a Chiari Type 1 malformation and a C6 to T7 syringomyelia. Six months after the initial surgery, the patient was referred to our institution after three weeks of gait disturbances and repeated falls. Imaging showed the gross misplacement of the left T5 pedicle screw, which crossed the center of the vertebral canal. The initial surgery used a freehand technique of pedicle screw insertion, with anteroposterior and lateral postoperative X-ray control. During the surgery, no SEP modifications were noted during pedicle screw placement. However, after insertion of the second rod and scoliosis correction by posterior translation technique, SEP responses decreased considerably. Revision surgery was performed to remove the misplaced screw. During the first three months after screw removal, repeated clinical examinations showed progressive recovery of the neurological deficits. Gait and bladder functions were normal six months after screw removal, and clinical signs of spasticity disappeared. SEP explorations performed at final follow-up showed similar responses to those performed before the initial surgery for scoliosis correction. DISCUSSION AND EVALUATION: Neurologic injury associated with pedicle screw malposition is rare. In early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Experimental studies have shown that neurophysiological monitoring of the spinal cord does not detect moderate compression. In that way, neurophysiological monitoring is an all-or-nothing technique which can misdiagnose early stage of spinal cord injuries. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal. CONCLUSIONS: In early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal.