Effects of Cast Immobilisation on Skin Barrier Function.

INTRODUCTION: Cast immobilisation remains the mainstay of treatment for various fractures in paediatric patients, yet patients commonly complain of skin irritation and discomfort. This study aimed to perform a qualitative and quantitative evaluation of the effects of cast immobilisation on the skin of children and adolescents. MATERIALS AND METHODS: Patients aged 6-17 years of age with a fracture treated in a fiberglass short-arm or short-leg cast were recruited. Transepidermal water loss (TEWL), stratum corneum (SC) hydration, hair density and presence of any skin signs were assessed before and after cast. Patients were required to complete a weekly questionnaire to rate itch, malodour, warmth, and dampness of the skin under the cast. RESULTS: A total of 60 subjects completed the study. Thirty-six patients received a short-arm cast; 24 received a short-leg cast. Upon cast removal, TEWL was significantly increased on the volar surface of the arms and legs (P <0.05), and the dorsal surface of the arm (P <0.05). Likewise, SC hydration was significantly increased at most sites (P <0.05), except the volar surface of the leg (P = 0.513). There was no change in hair density. Throughout the duration of casting, there was an increase in itch and malodour scores. CONCLUSION: Moderate but significant changes in TEWL, SC hydration and subjective symptoms were observed during the duration of cast immobilisation, demonstrating that cast immobilisation for up to 4 weeks exerts moderate adverse impact on patients' skin. Further studies to explore the use of better materials for cast immobilisation to improve skin barrier function and overall patient satisfaction are warranted.

The single visit treatment of pediatric distal radius buckle fractures-A center's experience with the treatment algorithm.

INTRODUCTION: This descriptive study aims to review and evaluate the implementation of a single visit treatment protocol for pediatric distal radius buckle fractures at our center - its success, learning points and limitations. It hopes to raise awareness of the efficacy of the protocol and its benefits to promote its utilization. METHODS: Following a pilot study, the protocol was implemented from 1 March 2017. A retrospective review of clinical records over 2 years since implementation for patients with a new-visit diagnosis of "distal radius buckle fracture" was conducted. Data collected included age at time of injury, gender, side of injury, whether the patient was enrolled into the protocol, number of clinic visits, and number of radiographic examination(s) performed. Each record was reviewed up to 3 months post-injury to check for any complications or return visits. Costs of specific treatment interventions were also obtained from the hospital's finance department. RESULTS: 286 patients with buckle fractures of the distal radius eligible for enrolment into the single visit treatment protocol were identified. Of these, 202 patients (70.6%) were enrolled and managed with the protocol, while 84 patients (29.4%) were treated with conventional management. Of the 202 protocol-managed patients, all fractures healed without complications. Only 4 patients returned for additional clinic visits. Another 4 patients had additional X-rays taken on top of their initial injury film. A breakdown of expenses for treatment also showed cost savings of USD 110.67 and USD 320.80 for residents and non-residents respectively for single visit treatment. CONCLUSION: Single visit treatment of pediatric distal radius buckle fractures is recommended and supported by evidence, with advantages of convenience, cost reduction, and being less labor intensive.

Paediatric supracondylar humeral fractures: a technique for safe medial pin passage with zero incidence of iatrogenic ulnar nerve injury.

INTRODUCTION: The cross Kirschner wire (K-wire) configuration in closed reduction and percutaneous pinning of paediatric supracondylar humeral fracture affords superior stability. However, medial pin placement presents a risk of iatrogenic ulnar nerve injury. This study describes, in step-by-step detail, another safe method of percutaneous medial pin insertion. METHODS: The technique involved placing the patient's arm in external rotation, with elbow flexed no more than 45° after closed reduction. The surgeon held the K-wire close to its sharp end to pass it percutaneously onto the medial epicondyle, then adjusted his grip toward the blunt end. After fluoroscopy check, the wire driver was engaged and an anteriorly directed force was applied to the distal humerus fragment using the thumb of the surgeon's free hand. The K-wire was inserted at a 45° angle to the longitudinal axis of the humerus shaft. Clinical notes and radiographs of patients who underwent surgery with this technique from 2006 to 2008 were reviewed. RESULTS: A total of 125 patients (84 boys, 41 girls) were included, with a mean age of 7.1 (range 2-14) years. Most injuries were left-sided (72.8%, n = 91, vs. right: 27.2%, n = 34). 72 (57.6%) patients had two-pin cross K-wire configuration, while 53 (42.4%) patients had an additional lateral pin inserted. No patient had postoperative ulnar neuropathy. There were no complications of non-union, malunion or infection. CONCLUSION: This safe method of medial pin placement for surgical stabilisation of paediatric supracondylar humeral fractures is easily learnt and reproducible, and produces excellent results.

The isolated medial humeral epicondyle fracture treated nonoperatively: does fracture displacement change over time?

This study explores the change in the position of the fragment in isolated, displaced, medial humeral epicondyle fractures in children. In this series, 34 patients (mean age 11.0 years) were treated nonoperatively by cast immobilization with no attempt at closed fracture reduction. A statistically significant association was found between the position of the fracture fragment at the time of initial fracture compared with 3 weeks after fracture (P=0.015). Twenty-six of 34 patients (76.5%) showed spontaneous improvement in fragment position. These findings support the practice of treating significantly displaced medial epicondyle fractures nonoperatively.