Open Reduction and Internal Fixation of a Pediatric Talar Body Fracture using a Medial Malleolar Osteotomy - A Case Report.

Introduction: Talus fracture injuries are rare and most literature pertains to fractures in skeletally mature adults. It is unusual for pediatric talus fractures to be treated operatively and is normally treated with immobilization. The location of the talus fracture required a medial malleolar osteotomy to facilitate exposure and reduction, which was fixed with temporary smooth K-wires. The authors were unable to identify a previous description of this technique in the literature. Case Report: An 11-year-old female was referred to our hospital due to polytraumatic injuries sustained in a roll-over MVC. A displaced fracture of the talus body was present. Due to the fracture location, a medial malleolar osteotomy was required for exposure. An open reduction and internal fixation was performed using subchondral minifragment screws under general anesthesia. The patient healed uneventfully, regained a normal gait and full, pain-free range of motion. Conclusions: Medial malleolar osteotomy with smooth K-wire fixation appears to be a safe method for gaining access to the talus when required for reduction and/or fixation of pediatric talus fractures.

Estimating cigarette tax avoidance and evasion: evidence from a national sample of littered packs.

INTRODUCTION: A number of recent studies document the proportion of all cigarette packs that are 'contraband' using discarded packs to measure tax avoidance and evasion, which we call tax non-compliance. To date, academic studies using discarded packs focused on relatively small geographical areas such as a city or a neighbourhood. METHODS: We visited 160 communities across 38 US states in 2012 and collected data from littered cigarette packs as part of the State and Community Tobacco Control (SCTC) Research Initiative and the Bridging the Gap Community Obesity Measures Project (BTG-COMP). Data collectors were trained in a previously tested littered pack data collection protocol. RESULTS: Field teams collected 2116 packs with cellophane across 132 communities. We estimate a national tax non-compliance rate of 18.5% with considerable variation across regions. Suburban areas had lower non-compliance than urban areas as well as areas with high and low median household income areas compared with middle income areas. DISCUSSION: We present the first academic national study of tax non-compliance using littered cigarette packs. We demonstrate the feasibility of meaningful large-scale data collection using this methodology and document considerable variation in tax non-compliance across areas, suggesting that both policy differences and geography may be important in control of illicit tobacco use. Given the geography of open borders among countries with varying tax rates, this simple methodology may be appropriate to estimate tax non-compliance in countries that use tax stamps or other pack markings, such as health warnings.

Spring Breaks and Cigarette Tax Noncompliance: Evidence From a New York City College Sample.

OBJECTIVE: Estimate cigarette tax noncompliance (tax avoidance and evasion) before and after mid-semester recesses in a New York City college campus, where the majority of students are residents of nearby lower-tax states, using data derived from garbology, an archaeological method that reconstructs patterns of human behavior from discarded materials. DESIGN: We systematically divided the college campus into four geographic areas and established a total of 12 transects (survey lines) and five quadrats (survey spheres) in those areas to encompass 74 outdoor trash cans. Weekly collections of discarded cigarette packs (n = 174) in the four areas during Spring 2012 and 2013 were conducted to quantify the percentage of cigarette packs that were tax noncompliant. RESULTS: Overall, we find that 72.4% of the cigarette packs collected in Spring 2012 and 2013 did not bear the required joint New York City and New York State tax stamp. Additionally, we find that cigarette tax avoidance significantly increased after recesses (mid-March and early April) in Spring 2012 and subsequently declined. We also find that packs with a Virginia tax stamp became more prevalent as time elapsed after each recess. CONCLUSION: College students practice tax avoidance, drawing on legal purchases from their own home states as the primary source of cheap cigarettes. As stocks decline, some students shift to tax evasion by illegally purchasing cigarettes in New York City that have been bootlegged from low tax states (eg, Virginia). IMPLICATIONS: Our study adds to the growing literature on cigarette tax noncompliance (ie, tax avoidance and evasion). First, we provide evidence that college students in our New York City sample avoid the payment of taxes in high tax states by purchasing low taxed cigarettes in their home state. Second, we find that once those sources are depleted, students find access to the black market nearby campus. This black market functions through cigarette tax evasion: the resale of cigarettes purchased in low tax states. Our study suggests that institutions of higher education operating in states with high cigarette taxes and a student body that resides in lower tax states should increase cessation services prior to breaks to discourage bulk purchases of cheap cigarettes.

Standardized posterior pelvic imaging: use of CT inlet and CT outlet for evaluation and management of pelvic ring injuries.

OBJECTIVES: The null hypothesis of this study states that routine axial computed tomography (CT) images are obtained at a consistent and reproducible orientation relative to the sacrum. The secondary null hypothesis states that there is no difference in the measurement of the safe zone for placement of iliosacral screws when using routine axial CT images and standardized reconstructions in defined planes perpendicular and parallel to the sacrum. DESIGN: Retrospective review. SETTING: University Level 1 Trauma Center. PATIENTS: Sixty-eight consecutive trauma patients evaluated with routine pelvic CT, without pelvic ring injury. INTERVENTION: Retrospective radiographic review and measurement. METHODS: Sixty-eight consecutive adult patients with routine axial pelvic CT scans, without injury to the pelvic ring, and obtained as part of a trauma evaluation were retrospectively identified. The orientation of the axial slices relative to the sacrum was measured for each patient and compared. The maximal cross-sectional distance at the smallest section of the sacral ala (safe zone) was measured using the routine axial CT images, and these measurements were compared with similar measurements taken on standardized images perpendicular (CT inlet) and parallel (CT outlet) to the body of the sacrum. Additional data referencing the orientation of multiple sacral radiographic landmarks were also collected. RESULTS: The orientation of routine axial CT image planes relative to the sacrum spanned a wide range. The angle between the routine axial CT plane and the sacrum varied from 43.5 to 82.0 degrees (SD = 9 degrees). Significant differences were found in measured safe zones of routine axial CT images compared with standardized CT inlet and CT outlet images. Compared with CT inlet images, routine axial CT images underestimated safe zones for transverse sacral screws at both S1 (P < 0.01) and S2 (P < 0.01). When compared with CT outlet images, routine axial CT images overestimated safe zones for oblique sacroiliac screws (P < 0.01) and underestimated the safe zone for S2 transverse sacral style screws (P < 0.01). No significant differences in measured variables were found between genders and sacral morphology. CONCLUSIONS: Our null hypotheses were rejected: routine axial CT images were found to be at widely ranging orientations relative to the sacrum, and standardized CT images (CT inlet and CT outlet) demonstrated statistically significant differences in measurements of safe zones compared with routine axial CT images. Furthermore, the CT inlet and CT outlet views provide additional information regarding sacral landmarks that could be useful for preoperative planning.

Upright versus supine radiographs of clavicle fractures: does positioning matter?

OBJECTIVES: To determine whether clavicle fracture displacement and shortening are different between upright and supine radiographic examinations. DESIGN: Combined retrospective and prospective comparative study. SETTING: Level I Trauma Center. PATIENTS: Forty-six patients (mean age, 49 years; range, 24-89 years) with an acute clavicle fracture were evaluated. INTERVENTION: Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the 2 positions. MAIN OUTCOMES MEASUREMENTS: One resident and 3 traumatologists classified the fractures and measured displacement and shortening. Data were aggregated and compared to ensure reliability with a 2-way mixed intraclass correlation. RESULTS: Fracture displacement was significantly greater when measured from upright radiographs (15.9 ± 8.9 mm) than from supine radiographs (8.4 ± 6.6 mm, P < 0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright but not on supine radiographs. Compared with the uninjured side, 3.0 ± 10.7 mm of shortening was noted on upright radiographs and 1.3 ± 9.5 mm of lengthening on supine radiographs (P < 0.001). The intraclass correlation was 0.82 [95% confidence interval (CI), 0.73-0.89] for OTA fracture classification, 0.81 (95% CI, 0.75-0.87) for vertical displacement, and 0.92 (95% CI, 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators. CONCLUSIONS: Increased fracture displacement and shortening was observed on upright compared with supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.

Cigarette trafficking in five northeastern US cities.

BACKGROUND: Cigarette taxation is effective in reducing tobacco use in the USA. However, these benefits are reduced when taxes are unpaid. Cigarette trafficking (ie, the illegal importation of cigarettes into a high-tax jurisdiction from a lower-tax jurisdiction) is well documented in high-tax places like New York City (NYC), but the extent of trafficking in other northeastern cities is relatively unknown. OBJECTIVE: To estimate the extent of cigarette trafficking in Boston, NYC, Philadelphia, Providence and Washington, DC, and project the benefits of reducing cigarette trafficking for recouping lost taxes and reducing smoking in these cities. METHODS: Littered cigarette packs were collected from a random sample of Census tracts in five US cities. Data collection yielded 1439 total littered packs. The share of cigarette packs bearing proper local, known non-local, foreign or unknown, or no tax stamp was calculated for each city. These data were used to estimate tax revenue recovery if cigarette trafficking could be eliminated. We also estimated the extent to which eliminating cigarette trafficking would reduce cigarette consumption. RESULTS: Overall, 58.7% of packs did not have a proper local tax stamp, and 30.5-42.1% were attributed to trafficking. We estimate that eliminating cigarette trafficking would result in declines in youth smoking prevalence ranging from negligible in low-tax cities like Philadelphia to up to 9.3% in higher-tax NYC. We estimate that these five cities could recoup $680-729 million annually in cigarette tax revenue if cigarette trafficking was eliminated. CONCLUSIONS: Reducing cigarette trafficking would increase the effectiveness of tobacco taxes in reducing smoking and generate additional tax revenue, particularly in higher-taxed cities. Federal action to reduce cigarette trafficking, such as a track-and-trace system, is needed.

Fixation strength of anteriorly inserted headless screws for talar neck fractures.

BACKGROUND: For noncomminuted talar neck fractures, traditional fixation is with small fragment screws or cannulated screws. Newer screw systems on the market allow placement of cannulated headless screws, which provide compression by virtue of a variable-pitch thread. The headless construct has an inherent advantage, particularly for the talus, when the screws must be countersunk to prevent wear of the joint articular surfaces. This study tested the biomechanical fixation strength of cannulated headless variable-pitch screws compared with conventional cannulated screws, both placed in an anterior to posterior direction. METHODS: A reproducible talar neck fracture was created in nine paired, preserved, cadaver talar necks using a materials testing machine. Talar head fixation was then performed with two cannulated headless variable-pitch 4/5 screws or two 4.0-mm conventional cannulated screws. The specimens were tested to failure and the fixations were normalized to their intact pairs and compared. RESULTS: The headless variable-pitch screw fixation had significantly lower failure displacement than the conventional screw fixation. No significant differences were found between the two fixations for failure stiffness, load at failure or energy absorbed. CONCLUSIONS: Cannulated headless variable-pitch screws significantly improved failure displacement when compared to conventional cannulated screws in a cadaveric model, and may be a viable option for talus fracture fixation. CLINICAL RELEVANCE: Headless, fully threaded, variable-pitch screws have inherent advantages over conventional screws in that they may be less damaging to the articular surface and can compress the fracture for improved reduction. This study demonstrates these screws are also biomechanically similar to conventional screws.

Is application of an internal anterior pelvic fixator anatomically feasible?

BACKGROUND: Spinal hardware has been adapted for fixation in the setting of anterior pelvic injury. This anterior subcutaneous pelvic fixator consists of pedicle screws placed in the supraacetabular region connected by a contoured connecting rod placed subcutaneously and above the abdominal muscle fascia. QUESTIONS/PURPOSES: We examined the placement of the components for anterior subcutaneous pelvic fixator relative to key vascular, urologic, bony, and surface structures. METHODS: We measured the CT scans of 13 patients after placement of the pelvic fixator to determine the shortest distances between the fixator components and important anatomic structures: the femoral vascular bundle, the urinary bladder, the cranial margin of the hip, the screw insertion point on the bony pelvis, the relationship between the pedicle screw and the corridor of bone in which it resided, and the position relative to the skin. RESULTS: The average distance from the vascular bundle to the pedicle screw was 4.1 cm and 2.2 cm to the connecting rod. The average distance from the connecting rod to the anterior edge of the bladder was 2.6 cm. The average distance from the screw insertion point to the hip was 2.4 cm; none penetrated the hip. The average screw was in bone for 5.9 cm. The pedicle screws were on average 2.1 cm under the skin. The average distance from the anterior skin to the connecting rod was 2.7 cm. CONCLUSIONS: Components of this anterior pelvic fixator are close to important anatomic structures. Careful adherence to the surgical technique should minimize potential risk. LEVEL OF EVIDENCE: Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.

Massive desmoplastic fibroblastoma with scapular invasion.

Desmoplastic fibroblastoma is a rare benign tumor usually associated with a favorable outcome. The tumor is characterized by fibroblastic cells that are sparsely distributed in a collagenous and fibromyxoid background. The growth of this tumor is generally indolent, and most tumors are small, subcutaneous lesions. They tend to behave in a nonaggressive manner, and several studies have reported no recurrences even after marginal excision. Invasion and destruction of bone are distinctly uncommon features.This article describes an unusual case of desmoplastic fibroblastoma that presented with a massive 23-cm tumor. The tumor was also unique for its infiltration and destruction of the scapula. The aggressive clinical features prompted the original physicians to administer chemotherapy, but the tumor exhibited no response to systemic treatment. The patient eventually underwent limb-sparing surgery at our hospital, which included en bloc resection, complete scapulectomy, and osteoarticular allograft replacement. The invasiveness of the tumor and its large size are distinctly unusual for desmoplastic fibroblastomas. Following surgical excision, the patient has remained continuously disease free for >5 years, which is in keeping with the intrinsically benign nature of the tumor. This case demonstrates that desmoplastic fibroblastoma can occasionally reach an enormous size and may exhibit invasive characteristics, but this does not necessarily portend subsequent recurrence of disease.

The impact of eliminating the global illicit cigarette trade on health and revenue.

AIMS: The purpose of this study was to update global estimates of the illicit cigarette trade, based on recent data, and estimate how many lives could be saved by eliminating it and how much revenue governments would gain. DATA SOURCES AND METHODS: Our estimates of illicit market share are based on formal and informal sources. Our method for estimating the effect of eliminating the illicit trade on tobacco related deaths is based on West et al. with some minor modifications, and involves calculating the size of the illicit cigarette trade; the effect of eliminating it on the price of cigarettes and thus on consumption; the revenue governments are losing because of it; and the number of tobacco-related premature deaths that would be avoided if this illicit trade were eliminated. RESULTS: According to available estimates, the size of the illicit trade varies between countries from 1% to about 40-50% of the market, 11.6% globally, 16.8% in low-income and 9.8% in high-income countries. The total lost revenue is about $40.5 billion a year. If this illicit trade were eliminated governments would gain at least $31.3 billion a year, and from 2030 onwards more than 164,000 premature deaths a year would be avoided, the vast majority in middle- and low-income countries. CONCLUSIONS: The burden of deaths and lost revenue caused by the illicit cigarette trade falls disproportionately on low- and middle-income countries. Eliminating this trade would avoid millions of premature deaths, and recover billions of dollars for governments.

Skimboard injuries.

BACKGROUND: Skimboarding is a recreational activity performed in shallow water in a beach setting. METHODS: We reviewed patient records from our emergency department for a 52-month period and identified 79 patients with skimboard-related injuries. RESULTS: Mean age of patients was 15.2 years; 73.4% presented with a fracture. Lower-extremity fractures were found 63.8% of the time, and upper extremity were found 36.2%. Distal radius fractures were the most common (61.9%) upper-extremity fracture, and ankle fractures were the most common (83.8%) lower-extremity fracture. The prevalence of fractures sustained while skimboarding was compared with that of other published series of recreational activities, including trampoline injuries, and was found to be higher. CONCLUSIONS: Skimboarding is a sport in which injuries occur by the sudden deceleration of the board as it transitions from water to land or from falls into shallow water. The lower-extremity fracture prevalence is much higher than in similar sports such as skateboarding and surfing. The prevalence of fracture is also higher than that found in trampoline-related injury reports.