Bivalved Versus Circumferential Cast Immobilization for Displaced Forearm Fractures: A Randomized Clinical Trial to Assess Efficacy and Safety.

BACKGROUND: The purpose of this study was to determine the effects of bivalved versus circumferential cast immobilization on maintenance of reduction and associated complications after closed reduction (CR) of radius and/or ulna fractures in children. METHODS: Two hundred two children with displaced radius and/or ulna fractures were randomized to either circumferential (n=101) or bivalved (n=101) long-arm casts after CR. The mean age was 10±3 years. There were no significant differences between groups in terms of age, sex, or initial fracture displacement or angulation. Clinical and radiographic evaluations were performed at 1, 2, 4, and 6 weeks postreduction. Radiographic loss of reduction (LOR), need for remanipulation or surgery, and associated complications of compartment syndrome, cast saw injury, and neurovascular compromise were recorded. RESULTS: Overall, the median angulation of the radius and ulna fractures improved from 20 and 18 degrees to 3 and 2 degrees after CR, respectively. The median cast index after reduction was 0.78 in the bivalved group and 0.80 in the circumferential group. The median angulation of the radius and ulna was 8 and 1 degrees at 4 weeks, with no significant difference between groups. By the fourth week of follow-up, 70 patients (34%)-35 bivalved and 35 circumferential-had radiographic LOR. Forty-seven patients (23%)-23 bivalved and 24 circumferential-underwent remanipulation or surgical reduction and fixation. There were no significant differences between groups with respect to LOR rate or need for surgical treatment. One bivalved patient sustained a cast saw injury, and 3 bivalved patients had transient neurological abnormalities. No patients developed compartment syndrome. CONCLUSIONS: Cast immobilization is effective in the majority of patients after CR of displaced forearm fractures. There were no significant differences in maintenance of reduction, need for surgery, or complications between bivalved or circumferential long-arm casts. LEVEL OF EVIDENCE: Level I-therapeutic.

Pharyngeal Flap Is Effective Treatment for Post Maxillary Advancement Velopharyngeal Insufficiency in Patients With Repaired Cleft Lip and Palate.

PURPOSE: Patients with repaired cleft lip and cleft palate (CL/P) can develop velopharyngeal insufficiency (VPI) after Le Fort I maxillary advancement. The aim of this study was to evaluate speech outcomes in patients who required a pharyngeal flap after Le Fort I maxillary advancement. PATIENTS AND METHODS: This retrospective cohort study included all patients with repaired CL/P who underwent a Le Fort I osteotomy and subsequently required a pharyngeal flap to correct VPI. Patients were included if they had outcome measurements documented at 3 time points: 1) before Le Fort I (baseline), 2) after Le Fort I, and 3) after pharyngeal flap. Outcome measurements, including speech characteristics (resonance, nasal emission, and intraoral pressure) and velopharyngeal function, were evaluated on perceptual assessment by a speech pathologist specializing in cleft care. Velopharyngeal closure was assessed with multi-view videofluoroscopy or nasopharyngoscopy. Patient characteristics and descriptive statistics were summarized and continuous data were expressed as mean ± standard deviation. Repeated-measures analysis of variance and paired samples t test were used to measure changes in speech outcome variables between time points. All P values were 2-tailed and considered significant for values less than .05. RESULTS: There were 23 patients for analysis (13 girls [56.5%] and 10 boys [43.5%]). Two patients (9%) had cleft palate only, 9 (39%) had unilateral cleft lip and palate (CLP), and 12 (52%) had bilateral CLP. Follow-up evaluations performed on average 12 months postoperatively showed statistically meaningful improvement for all variables, including decreased hypernasality, reduced nasal emission, and increased intraoral pressure for consonant production. Patients with repaired CL/P who had VPI after Le Fort I maxillary advancement showed significant improvement in all outcome measurements after pharyngeal flap (P < .001). CONCLUSIONS: The superiorly based pharyngeal flap is highly successful in correcting VPI after Le Fort I maxillary advancement in patients with repaired CL/P.

Change in Mandibular Position in Patients With Syndromic Craniosynostosis After Midfacial Advancement With Distraction Osteogenesis.

OBJECTIVE: Characterize mandibular morphology in patients with syndromic craniosynostosis and document changes in mandibular position following midfacial advancement using distraction osteogenesis (DO). DESIGN: Retrospective chart review and analysis of cephalometric radiographs. SETTING: Tertiary care center. PATIENTS: Patients with syndromic craniosynostosis who had midfacial advancement with DO at Boston Children's Hospital between 2000 and 2012. Mandibular morphology was characterized in 26 patients (15 boys and 11 girls) with a mean age of 11 years, 9 months. Pre- and postoperative analyses were performed for 17 (10 boys and 7 girls) of the 26 patients with a mean age of 11 years, 9 months. MAIN OUTCOME MEASURES: Mandibular morphology and mandibular position. Data were compared to standard data from the Michigan Growth Study. RESULTS: Comparison of preoperative mandibular measurements to standard data showed that patients with syndromic craniosynostosis have a shorter mandibular body and length and an obtuse gonial angle. Comparison of pre- and postoperative cephalograms showed that, following midfacial advancement with DO, the maxilla moved forward and the mandible moved backward and downward. CONCLUSIONS: Patients with syndromic craniosynostosis have a smaller mandible length and obtuse gonial angle. Correction of midfacial hypoplasia with DO results in inferior and posterior mandibular movement. Clinicians can use this information to counsel patients regarding anticipated changes in facial profile and the need for adjunct procedures.

Anatomic Severity, Midfacial Growth, and Speech Outcomes in Van der Woude/Popliteal Pterygium Syndromes Compared to Nonsyndromic Cleft Lip/Palate.

OBJECTIVE: To summarize the clinical characteristics and surgical and speech outcomes for patients with Van der Woude/popliteal pterygium syndromes (VWS/PPS) and to compare them with a historic cohort of patients with nonsyndromic cleft lip/cleft palate (CL/P). DESIGN: Retrospective chart review. SETTING: Tertiary care center. PATIENTS: All patients with VWS/PPS seen at Boston Children's Hospital from 1979 to 2012: 28 patients with VWS (n = 21)/PPS (n = 7) whose mean age was 17.3 ± 10.4 years, including 18 females (64%) and 10 males (36%); 18 patients (64%) had a family history of VWS/PPS. MAIN OUTCOME MEASURES: Cleft type, operative procedures, speech, and midfacial growth. Data were compared with historic cohorts of patients with nonsyndromic CL/P treated at one tertiary care center. RESULTS: There were 24 patients (86%) with CP±L, Veau types I (n = 4, 17%), II (n = 4, 17%), III (n = 5, 21%), and IV (n = 11, 46%). Nine patients (38%) had palatal fistula after palatoplasty. Fourteen of 23 (61%) patients with CL/P age 5 years or older had midfacial retrusion, and 10 (43%) required a pharyngeal flap for velopharyngeal insufficiency. Fisher's exact test demonstrated higher frequencies of Veau type IV CP±L (P = .0016), bilateral CL±P (P = .0001), and complete CL±P (P < .0001) in VWS/PPS compared with nonsyndromic patients. Incidences of midfacial retrusion (P = .0001), palatal fistula (P < .0001), and need for pharyngeal flap (P = .0014) were significantly greater in patients with VWS/PPS. CONCLUSIONS: Patients with VWS/PPS have more severe forms of labiopalatal clefting and higher incidences of midfacial retrusion, palatal fistula, and velopharyngeal insufficiency following primary repair as compared with nonsyndromic CL/P.

Intra-articular corrective osteotomy of humeral lateral condyle malunions in children: early clinical and radiographic results.

BACKGROUND: Intra-articular malunions of pediatric humeral lateral condyle fractures may lead to pain, loss of motion and function, deformity, and elbow arthritis. Little information is available, however, regarding the treatment of symptomatic articular malunions. The purpose of this investigation is to report early results of intra-articular osteotomy of lateral condyle malunions in children. METHODS: Seven patients who underwent intra-articular osteotomies for lateral condyle malunions were evaluated. Clinical records and radiographs were reviewed for demographics, fracture characteristics, initial fracture care, surgical technique, and early clinical and radiographic results. Outcomes were classified according to the Dhillon score. RESULTS: Mean age at time of injury was 8.1 years (range, 4.3 to 11.4 y). Three patients had Milch type I fractures; 4 had Milch type II fractures. The mean interval from injury to osteotomy was 10 months. Two patients were initially treated with cast immobilization, and 5 underwent surgical treatment with either percutaneous pin fixation (n=2) or open reduction internal fixation (n=3). Before osteotomy, mean arc of elbow motion was 60 degrees (range, 40 to 100 degrees), average Dhillon score was 4 (range, 3 to 6), and average Baumann angle was 75 degrees. Postoperatively, mean elbow arc of motion improved to 105 degrees (range, 60 to 140 degrees) (P=0.028), and mean Dhillon score improved to 5.6 (range, 3 to 7) (P=0.02). There was a trend toward better postoperative Dhillon scores in patients with Milch type I (mean 7) versus Milch type II injuries (mean 4.5) (P=0.12). Average Baumann angle postoperatively was 85 degrees. Two patients had persistent radiographic evidence of osteonecrosis of the capitellum or trochlea at most recent follow-up, consistent with preoperative imaging. CONCLUSIONS: Intra-articular corrective osteotomy may improve range of motion in patients with functionally limiting elbow stiffness due to lateral condyle malunion. Milch I fracture malunions may be more amenable to surgical correction than fractures extending into the trochlea. Preservation of soft tissue attachments to the lateral condylar fragment is recommended to minimize the risk of subsequent osteonecrosis. LEVEL OF EVIDENCE: IV (retrospective case series).

Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders.

BACKGROUND: The International Knee Documentation Committee (IKDC) Subjective Knee Form is a knee-specific measure of symptoms, function, and sports activity. A modified IKDC Subjective Knee Form (pedi-IKDC) has been developed for use in children and adolescents. The purpose of this study was to determine the psychometric characteristics of the pedi-IKDC in children and adolescents with knee disorders. HYPOTHESIS: The pedi-IKDC is a reliable, valid, and responsive patient-administered outcome instrument in the pediatric population with knee disorders. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Test-retest reliability, content validity, criterion validity, construct validity, and responsiveness to change were determined for the pedi-IKDC in patients aged 10 to 18 years with a variety of knee disorders. Test-retest reliability was measured in a group of 72 patients with a stable knee disorder. Validity was measured in a group of 589 patients with the Child Health Questionnaire to determine criterion validity. Responsiveness was measured in a group of 98 patients undergoing a variety of knee surgical procedures. RESULTS: The overall pedi-IKDC had acceptable test-retest reliability (intraclass correlation coefficient, .91) and excellent internal consistency (Cronbach alpha, .91). The form also demonstrated acceptable floor (0%) and ceiling (6%) effects. There was acceptable criterion validity with significant (P < .01) correlation between the overall pedi-IKDC and 9 relevant domains of the Child Health Questionnaire. Construct validity was acceptable, with all 11 hypotheses demonstrating significance (P < .0001). Responsiveness to change was acceptable (effect size, 1.39; standardized response mean, 1.35). CONCLUSION: The pedi-IKDC demonstrated overall acceptable psychometric performance for outcome assessment of children and adolescents with various disorders of the knee.