Common Pediatric Fractures for Community Orthopaedic Specialists: Fix Them or Ship Them?

It is important to focus on common pediatric fractures seen in community emergency rooms, including supracondylar humerus, elbow, forearm, distal radius, and femoral shaft fractures, along with periarticular fractures around the knee and ankle in children. The principles of surgical and nonsurgical management of these fractures are based on the fracture type and age of the patient. The orthopaedic surgeon should be aware of important tips and tricks to help manage these injuries and be familiar with common complications that may occur when these injuries are encountered during trauma call.

Subtalar joint preparation using the Two Portal posterior arthroscopic technique versus the sinus tarsi Open approach: A cadaver study.

BACKGROUND: Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. The procedure can be performed arthroscopically or through the open lateral sinus tarsi (LST) approach. The arthroscopic technique is less invasive and is associated with rapid recovery, but it is more technically challenging. One of the most important aspects of fusion is adequate preparation of the joint via denudation of articular cartilage. This study compares the efficacy of subtalar joint preparation between the lateral sinus tarsi approach and the posterior two-portal arthroscopic technique using cadaveric specimens. MATERIALS AND METHODS: Nineteen below-knee fresh-frozen cadaver specimens were used. The subtalar joints of nine specimens were prepared through the LST approach, while ten were prepared arthroscopically. After preparation, all ankles were dissected at the subtalar joint and photographs were taken of the posterior facets of the calcaneus and talus. Total and prepared surface areas of the articular surfaces for both approaches were measured using ImageJ software and compared. RESULTS: The LST technique resulted in significantly greater percent preparation of the posterior facet of the calcaneus, as well as of the subtalar joint as a whole. Overall, 92.3% of the subtalar joint surfaces (talus and calcaneus combined) were prepared using the LST technique, compared to 80.4% using the arthroscopic technique (p = 0.010). The posterior facet of the calcaneus was 94.0% prepared using the open technique, while only 78.6% prepared using the arthroscopic technique (p = 0.005). CONCLUSION: The LST approach for subtalar arthrodesis provides superior articular preparation compared to the two-portal posterior arthroscopic technique. Given that joint preparation is a critical component of fusion, maximizing prepared surface area is desirable and the open approach may be more efficacious for fusion. When using the arthroscopic approach, it may be advisable to use an accessory portal if there is poor visualization or limited access to the joint space secondary to severe arthritis. LEVEL OF EVIDENCE: V.

Robotic Arm-Assisted Total Knee Arthroplasty in the Setting of Combined Extra-articular Deformities of the Femur and Tibia.

In this case, we will describe a 68-year-old man with combined femoral and tibial bone deformities who underwent robotic arm-assisted total knee arthroplasty (RATKA) to treat his severe osteoarthritis in the setting of extra-articular deformities that altered the native anatomical axis and the kinematics of the deformed extra-articular bony structures which chronically generated a neomechanical axis. The combination of severe osteoarthritis with extra-articular deformities made the RATKA method the best surgical treatment option taking into account altered kinematics of the native joint which conventional jig-based total knee arthroplasty would not have prioritized during bony cuts and implant positioning. The patient underwent successful knee arthroplasty with robotic arm-assisted technology with restoration of the mechanical axis.

Landmark Technique vs Ultrasound-Guided Approach for Posterior Tibial Nerve Block in Cadaver Models.

BACKGROUND: The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the accuracy and efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged behind in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. The objective of this study was to compare the accuracy of traditional anatomical landmark-guided technique with an ultrasound-guided approach for ankle block by assessing the spread of injectate along the posterior tibial nerve (PTN) in cadaver models. MATERIALS AND METHODS: Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo anatomical landmark-guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The anatomical landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN, with the needle subsequently advanced in-plane with a posterior to anterior trajectory until the tip was adjacent to the nerve. Each specimen was injected with 2 mL of acrylic dye. All the specimens were dissected following injection to determine which nerves had been successfully coated with dye. RESULTS: The PTN was successfully coated with dye in all five (100%) ultrasound-guided blocks. In the anatomical landmark group, two (40%) PTN were successfully coated with dye. Of the three unsuccessful attempts, two specimens were noted to have dye injected posterior to the PTN; dye was injected into the flexor digitorum longus tendon in one. CONCLUSION: The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate of delivering a simulated nerve block to the correct anatomic location.

Bilateral tibial tubercle sleeve fractures in a skeletally immature patient.

Tibial tubercle sleeve fracture is a rare injury. In concept, it is similar to the patellar sleeve fracture in a skeletally immature patient. We describe a unique case of simultaneous bilateral tibial tubercle sleeve fractures in a 12-year-old boy. Radiographs and MRI confirmed the injury. The patient underwent open surgical repair of bilateral sleeve fractures with suture anchor fixation. At the final followup, 3 years after his initial injury, the patient demonstrated full knee function bilaterally without radiographic evidence of growth disturbances.

Revision total hip arthroplasty using a modular femoral implant in Paprosky type III and IV femoral bone loss.

The purpose of this study was to compare results of patients with Paprosky type I and II femoral defects vs type IIIA, IIIB, and IV defects in patients undergoing revision hip arthroplasty. There were 64 patients in the group with type I and II defects with an average age of 68 years. There were 52 patients with Paprosky type IIIA, IIIB, and IV defects with an average age of 67 years. There were 8 intraoperative fractures in the type III and IV group, whereas there were 9 in the type I and II group. There were no differences between the 2 groups with respect to subsidence, loosening, dislocation, infection, and medical complications. Survivorship for the whole group was 96.9% at 5 years. Modular femoral implants provide several intraoperative options to restore leg length, offset, and stability despite femoral defects. We did not realize a higher failure rate in patients with type III or IV defects.

Could junctional problems at the end of a long construct be addressed by providing a graduated reduction in stiffness? A biomechanical investigation.

STUDY DESIGN: The effect of long, rigid fixation on adjacent level hypermobility was investigated in a human cadaver model with and without a transitional posterior dynamic stabilization (PDS) device placed at the last caudal level. OBJECTIVE: To evaluate if PDS devices are useful in the setting of spinal deformities to restore increased adjacent level motions, which occur in long constructs. The hypothesis is that load-sharing benefits of these devices will be most suitable in long constructs and may reduce thoracolumbar junctional effects. The PDS device evaluated has a compressive spacer and flexion-dampening bumper. SUMMARY OF BACKGROUND DATA: Mechanical factors such as excessive mobility, increased disc height due to instrumentation, and abnormal loading are thought to accentuate distal level problems, which occur in extended instrumentation. Specifically adjacent level degeneration and distal junctional kyphosis are known to occur in these cases. METHODS: Seven cadaver spines were tested from T7 to L3. Long instrumentation was applied in 2 rigid groups, R1: Rigid (T8-L2) and R2: Rigid (T8-L1), and PDS to the last caudal level of each, RP1: Rigid (T8-L1) + PDS (L1-L2), and RP2: Rigid (T8-T12) + PDS (T12-L1). Range of motion was evaluated at surgical and distal adjacent levels after displacement controlled loading in a spine tester. RESULTS: Distal adjacent level motion was increased after 5- and 6-level rigid fixation in flexion-extension, lateral bending, and axial rotation. Most of the increases were seen in axial rotation and lateral bending. Replacing the last caudal instrumented level with the PDS test device was able to alleviate hypermobile conditions of the adjacent noninstrumented level, closer to intact (24%, 12% reduction in RP2, RP1, respectively). CONCLUSION: Reduction of hypermobility caused by extended arthrodesis may represent a new and ideally suited function for PDS devices. Mechanically, the devices were seen to kinematically restore abnormal distal motion, especially with placement of the PDS at the thoracolumbar junction.

Intra-articular entrapment of the medial collateral ligament.

The medial collateral ligament (MCL) is the most commonly injured knee ligament. Such injuries in children are rare due to the relative thickness of the articular cartilage and physes that can absorb energy. Traumatic MCL entrapment into the medial knee joint in a child has not yet been reported. This article presents a case of intra-articular MCL entrapment in a 9-year-old boy with characteristic findings on magnetic resonance imaging (MRI) showing the interposition of the MCL between the medial meniscus and medial tibial plateau. During arthroscopic surgery, the MCL tear pattern was visualized underneath the medial meniscus. A medial knee incision was performed and the MCL was retrieved from the knee joint. The meniscotibial ligaments and medial meniscus were repaired to the tibial plateau. The torn ends of MCL were reapproximated and sutured. One year postoperatively, the patient is back to full activities including sports without limitations. This article should help raise awareness about the possibility of such injuries to avoid a delay in diagnosis. Although it is true that children would injure their physes more often than their ligaments due to their relative weakness, this article describes the possibility of a serious ligament injury without physeal involvement.

C-1 lateral mass screw fixation in children with atlantoaxial instability: case series and technical report.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the feasibility, safety, and efficacy of incorporating C-1 lateral mass screws into fusion constructs in children with atlantoaxial instability. SUMMARY OF BACKGROUND DATA: The operative treatment of atlantoaxial instability varies widely based on anatomy, patient age, and surgeon preference. The modified Harms construct, consisting of polyaxial C-1 lateral mass screws together with C-2 pedicle or pars screws and rods, has shown satisfactory fusion rates and minimal incidence of complications in adult patients. However, its utility in the pediatric population remains unproven, largely because of the technical challenges and risks inherent in placing C-1 lateral mass screws in children with immature bone quality, extensive anatomical variability, and smaller osseous structures. METHODS: We retrospectively reviewed the records of all pediatric patients with atlantoaxial instability treated surgically, with a fusion construct incorporating C-1 lateral mass screws, at our institution between July 1, 2005 and June 30, 2008. Eight patients were identified and their relevant clinical data were abstracted from the medical record. RESULTS: All patients had C-1 lateral mass screws placed as part of a fixation construct. Six cases used C-2 pedicle screws and 2 cases used C-3 lateral mass screw fixation for the inferior portion of the construct. There were 6 female and 2 male patients. Age at the time of the surgery ranged from 5 to 13 years (mean 9 y), and follow-up ranged from 11 to 38 months (mean 23 mo). No C-2 nerve root was sacrificed in any patient. There were no intraoperative or postoperative complications, including neurological injury, vascular injury, or hardware-related complications. Successful fusion was documented with dynamic cervical spine radiography in all cases. CONCLUSIONS: C-1 lateral mass screw placement is generally feasible and safe in pediatric patients. With a nearly 2-year average follow-up, C1-2 rigid screw/rod fixation has proven to be an effective treatment modality for pediatric atlantoaxial instability in our series.

Congenital anterior urethral diverticulum with stone: a unique presentation.

We report the case of an 18-month-old boy with a congenital anterior urethral diverticulum containing an elliptical stone at the penoscrotal junction, with urinary retention and extravasation of urine. Initial management consisted of an open suprapubic cystostomy. Three weeks after resolution of extravasation, diverticulectomy with removal of the stone by urethroplasty was done after ruling out associated obstructing anterior urethral valves.

The Dretler stone cone: a device to prevent ureteral stone migration-the initial clinical experience.

PURPOSE: Retrograde stone migration during ureteroscopic lithotripsy occurs in 5% to 40% of proximal and distal ureteral stone cases. This migration increases morbidity and the need for auxiliary procedures. The Dretler stone cone (Medsource, Norwell, Massachusetts) is a novel device to prevent proximal stone migration and facilitate fragment extraction during ureteroscopic lithotripsy. We assessed the safety and efficacy of the Dretler stone cone in the clinical setting and compared it prospectively with a conventional flat wire basket during ureteroscopy for ureteral calculi. MATERIALS AND METHODS: To our knowledge we report the initial clinical use of the Dretler stone cone in 50 consecutive patients with ureteral calculi undergoing ureteroscopic extraction. Calculi were situated above the sacroiliac joint in 24 cases, over the sacroiliac joint in 15 and below the sacroiliac joint in 11. Pneumatic lithotripsy was done in 42 cases. In the remaining 8 cases ureteroscopic (3) or fluoroscopic (5) intact stone extraction was performed. The later 23 cases using the Dretler stone cone were prospectively compared with 20 of ureteroscopic intracorporeal lithotripsy using a standard flat wire basket. RESULTS: The Dretler stone cone was successfully placed in all 50 cases. In 41 patients it was placed via cystoscopy under fluoroscopic guidance, while 9 impacted stones required ureteroscopic placement. Six patients in whom the Dretler stone cone was used had residual fragments less than 3 mm. No patient required auxiliary procedures. In the prospective trial no patients in Dretler stone cone group had residual fragments greater than 3 mm. or required auxiliary procedures. However, in the flat wire basket group residual stones greater than 3 mm. were present in 6 cases (30%, p <0.001), while auxiliary procedures were required in 4 (20%, p <0.01). CONCLUSIONS: The Dretler stone cone represents a new generation of basketry that minimizes proximal ureteral stone migration and allows safe extraction of fragments during ureteroscopic lithotripsy. In our experience it is associated with a lower incidence of significant residual fragments and fewer auxiliary procedures than conventional flat wire baskets.