The importance of adequate diagnosis of pediatric forearm bowing fractures: A case report.

INTRODUCTION: Correct diagnosis of pediatric bowing fractures has proven to be challenging. Consequently, these entities are often underdiagnosed both at the initial presentation and at further follow-up. We present a case of an ulnar fracture with subsequent non-union and initially missed associated plastic deformity of the radius to highlight the importance of adequate diagnosis of bowing fractures and obtaining appropriate imaging in pediatric forearm trauma to prevent sequelae. CASE PRESENTATION: A 13-year old male sustained a diaphyseal fracture of the left ulna after a fall on the outstretched hand which was treated conservatively. A non-impact incident (push up on outstretched arm) 4.5 months after the initial trauma caused an ulnar fracture at the same location and was initially considered a simple refracture. Operative treatment was decided on due to significant clinical forearm valgus alignment. Intraoperatively however, a mobile non-union of the ulna was found and anatomic reduction was not possible due to radial bowing. Exploration of the radius showed a clear malalignment with periosteal callus reaction, indicative of a mal-union of the radial bone as a result of the initial injury. To correctly restore alignment, a closing wedge osteotomy of the radius was necessitated followed by plate and screw fixation of both the radius and the ulna. CONCLUSION: In this patient, failure of recognizing the associated plastic deformity of the radius during the initial presentation led to radial malunion and non-union of the ulna. As a result of this complication, an osteotomy was necessary which probably could have been prevented if an adequate initial diagnosis had been made.

Short stem total hip arthroplasty: Potential explanations for persistent post-surgical thigh pain.

Short stem uncemented femoral implants were developed with the aim of preserving proximal bone stock for future revisions, improving biomechanical reconstruction, aiding insertion through smaller incisions and potentially decreasing or limiting the incidence of thigh pain. Despite all the advantages of short stem designs, it remains unclear whether they are able to limit post-surgical thigh pain. In patients with short stem hip arthroplasty and persistent thigh pain, it is of the utmost importance to understand the potential etiologies of this chronic pain for selecting the appropriate treatment strategy. Therefore, this manuscript explores the hypothetical etiologies of persistent thigh pain in short stem total hip arthroplasty, including both peripheral factors (structural or biomechanical causes) and central factors (involvement of the central nervous system). First, intrinsic causes (e.g. aseptic femoral loosening and prosthetic joint infection) and extrinsic sources (e.g. muscle pathology or spinal pathology) of persistent thigh pain related to hip arthroplasty are explained. In addition, other specific peripheral causes for thigh pain related to the short stem prosthetic reconstruction (e.g. stem malalignment and micro-motion) are unraveled. Second, the etiology of persistent thigh pain after short stem hip arthroplasty is interpreted in a broader concept than the biomechanical approach where peripheral structural injury is believed to be the sole driver of persistent thigh pain. Over the past decades evidence has emerged of the involvement of sensitization of central nervous system nociceptive pathways (i.e. central sensitization) in several chronic pain disorders. In this manuscript it is explained that there might be a relevant role for altered central nociceptive processing in patients with persistent pain after joint arthroplasty or revision surgery. Recognition of a potential role for centrally-mediated changes in pain processing in total hip replacement surgery has important implications for treatment. Comprehensive treatment addressing peripheral factors as well as neurophysiological changes occurring in the nervous system may help to improve outcomes in patients with short stem hip arthroplasty and chronic thigh pain. Working within a biopsychosocial approach in orthopaedic surgery, specifically in relation to total hip arthroplasty, could be very important and may lead to more satisfaction. Further research is warranted.

Plate fixation of middle-third fractures of the clavicle in the semi-professional athlete.

From 1995 to 2003, 39 semi-professional athletes (34 men and 5 women) aged 17-34 years (mountain bike racers, soccer players, swimmers and cyclists) with a displaced fracture of the middle-third of the clavicle were treated operatively using rigid plate fixation within one week after the initial trauma. In 90% of the athletes, radiographic union was achieved after 12 weeks. At 6 weeks post-operatively the mean Constant score was 88 points, the mean visual analogue pain score was 3 out of 10 and the average time for return to sports was 45 days. Seventy-five percent of the patients were very satisfied with the end-result and 95% would chose to have the same operation again. In 5% of the cases the end-result was unsatisfactory. The most frequent postoperative complication was wound infection (18% of the cases). Nevertheless, this did not affect the outcome. Other postoperative complications in our athletic population included refracture (5%), transient neurological complications (7%) and non-union (5%), which were equally low in the literature. These data suggest that rigid plate fixation of middle-third clavicle fractures gives good results in the semi-professional athlete and may result in early return to sports activity, at the expense of a significant risk for complications, which would not be considered acceptable in patients with lower functional demands.