The Use of Magnetic Resonance Imaging in Management of Minimally Displaced or Nondisplaced Lateral Humeral Condyle Fractures in Children.

OBJECTIVES: Fractures of the lateral humeral condyle are common in children. Nondisplaced fractures are managed with cast immobilization and frequent radiographic follow-up. Possibility of assessing the displacement and stability of such fractures may be helpful in planning the initial treatment and survey. Magnetic resonance imaging (MRI) could be a useful tool in determining the stability of lateral condyle in children. We propose to investigate the use of MRI in such indication. METHODS: Fourteen patients presenting with a minimally displaced or nondisplaced fracture were initially treated with a long arm cast and had an MRI within 5 days of injury. RESULTS: The MRI showed that 10 patients had an incomplete fracture without disruption of the cartilage hinge and 4 patients had a complete fracture with extension of the fracture through the cartilaginous epiphysis into the elbow joint. Three patients with such complete fracture had no evidence of lateral condyle displacement on MRI, and 1 patient had a displacement of the lateral condyle. The patients with incomplete fractures had a conservative treatment. The patient with a complete and displaced fracture had an open reduction and internal fixation. The 3 patients with a complete fracture and no evidence of lateral condyle displacement on MRI had a control MRI, 6 to 10 days after cast application, to detect a secondary displacement of the fracture. CONCLUSIONS: Because it seems difficult in minimally displaced or nondisplaced fractures to detect further displacement with radiographs, MRI was found mandatory to improve complete fracture visualization during the first phase of conservative treatment. In incomplete fractures, initial MRI investigation was consistent with a stable fracture and avoided further early radiographs or clinical survey. In such cases, we recommend a conservative treatment with late radiographs after long arm cast removal. We propose MRI routine use in the early evaluation of minimally displaced or nondisplaced lateral condyle fractures in children.

CoCr rods provide better frontal correction of adolescent idiopathic scoliosis treated by all-pedicle screw fixation.

PURPOSE: Pedicle screw fixation is considered biomechanically advantageous in adolescent idiopathic scoliosis (AIS) correction, because it uses as an anchor the pedicle, which is the hardest part of the vertebral body. The ability of the rod to correct and hold the correction is a key factor in the selection of rod material. The goal of this study was to compare the results obtained by stainless steel (SS) and cobalt-chromium (CoCr) rods materials for the treatment of AIS curves. METHODS: Ninety patients were retrospectively included. Sixty-four patients (group 1) were operated on using CoCr rods. Twenty-six patients (group 2) were operated on using SS rods. All the patients were treated by the same surgeon using all-pedicle screw constructs. RESULTS: In group 1, the correction was respectively 41.03° and 35.78° for main and secondary curves. In group 2, the correction was respectively 30.98° and 24.42° for main and secondary curves. Statistical analysis showed improved correction rates in patients operated with CoCr rods for main (P < 0.0001) and secondary (P = 0.0003) curves with a lower loss of correction at final follow-up. Regarding the sagittal profile, postoperative T4T12 thoracic kyphosis was 28.04° in CoCr group compared to 22.79° in SS group (P = 0. 0.0038). DISCUSSION: The present study confirms the ability of the all-pedicle screw construct to reach the maximum coronal plane correction and prevent deformity progression while maintaining balance. CoCr rods have the ability to exert higher corrective forces on the spine with relatively small amounts of rod deformation. Our findings confirm that CoCr rods have the ability to produce higher correction rates in frontal plane compared to SS rods of the same diameter.

All-Pedicle Screw Fixation With 6-mm-Diameter Cobalt-Chromium Rods Provides Optimized Sagittal Correction of Adolescent Idiopathic Scoliosis.

PURPOSE: Recently introduced cobalt-chromium (CoCr) rods that rely solely on pedicle screws produce very good results in correcting scoliotic curves. All-pedicle screws constructs are also suspected of decreasing thoracic kyphosis. The current study was designed to evaluate sagittal correction in adolescent idiopathic scoliosis patients, using 6-mm CoCr rods and all-screw constructs. MATERIALS AND METHODS: A total of 61 patients treated by posterior spinal fusion and instrumentation, using all-pedicle screw constructs were included. The mean age at surgery was 15.4 years (range, 12-18 y). Forty-five patients (group A) were diagnosed with decreased thoracic kyphosis, and 16 patients (group B) had normal (35-50 degrees) thoracic kyphosis. RESULTS: The preoperative main Cobb angle was 62.93±19.38 degrees in group A and 73.45±22.13 degrees in group B. In group A, the postoperative main Cobb angle was 23.33±12.71 degrees. In group B, the postoperative main Cobb angle was 27.20±10.04 degrees. The T4-T12 thoracic kyphosis improved postoperatively from 18.15±10.29 to 28.18±8.35 degrees in group A. In group B, the postoperative T4-T12 thoracic kyphosis was 40.34±3.13 degrees. Statistical analysis showed a significant improvement between preoperative and postoperative values of T4-T12 thoracic kyphosis in group A. In group B, the differences in T4-T12 thoracic kyphosis values were not statistically significant. CONCLUSIONS: Our result demonstrates a significant improvement of T4-T12 thoracic kyphosis in the hypokyphotic group of patients and confirms that CoCr rods can produce sagittal corrections in hypokyphotic adolescent idiopathic scoliosis patients. Our results confirm the benefit of combining all-pedicle screw constructs with a posterolateral translational in situ bending procedure to correct hypokyphosis directly.

The Indian Basket Trick: a case of delayed paraplegia with complete recovery, caused by misplaced thoracic pedicle screw.

INTRODUCTION: Pedicle screw fixation allows purchase of all three spinal columns without encroaching into the spinal canal improving fracture fixation, as well as deformity correction. Fortunately, neurologic injury associated with pedicle screw malposition is rare. CASE PRESENTATION: A 19-year-old boy was surgically treated for severe right thoracic scoliosis associated with a Chiari Type 1 malformation and a C6 to T7 syringomyelia. Six months after the initial surgery, the patient was referred to our institution after three weeks of gait disturbances and repeated falls. Imaging showed the gross misplacement of the left T5 pedicle screw, which crossed the center of the vertebral canal. The initial surgery used a freehand technique of pedicle screw insertion, with anteroposterior and lateral postoperative X-ray control. During the surgery, no SEP modifications were noted during pedicle screw placement. However, after insertion of the second rod and scoliosis correction by posterior translation technique, SEP responses decreased considerably. Revision surgery was performed to remove the misplaced screw. During the first three months after screw removal, repeated clinical examinations showed progressive recovery of the neurological deficits. Gait and bladder functions were normal six months after screw removal, and clinical signs of spasticity disappeared. SEP explorations performed at final follow-up showed similar responses to those performed before the initial surgery for scoliosis correction. DISCUSSION AND EVALUATION: Neurologic injury associated with pedicle screw malposition is rare. In early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Experimental studies have shown that neurophysiological monitoring of the spinal cord does not detect moderate compression. In that way, neurophysiological monitoring is an all-or-nothing technique which can misdiagnose early stage of spinal cord injuries. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal. CONCLUSIONS: In early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal.

How can surgeonfish help pediatric surgeons? A pilot study investigating the antinociceptive effect of fish aquariums in adult volunteers.

BACKGROUND: Multiple distraction strategies have been proposed to reduce the incidence of anxiety and pain in children. Animal-assisted therapy is acknowledged and used in children as an adjunctive treatment with cognitive, physical, psychosocial and spiritual benefits. OBJECTIVE: To determine the effect of fish aquarium animal-assisted therapy (FA-AAT) on pain perception in a cohort of healthy volunteers. METHODS: Sixty-nine healthy subjects (mean age 27.3 years) were exposed to >20 different species of soft or hard corals and >25 fish in a 1000 L saltwater aquarium. Pain perception was assessed using an electrical stimulation device, the Pain Matcher (Cefar Medical AB, Sweden), after 5 min, 10 min, 20 min and 30 min of continuous aquarium viewing. The measurements were repeated 10 min after stopping aquarium viewing. RESULTS: A statistically significant pain perception threshold augmentation was observed after a 5 min aquarium viewing. This threshold augmentation was also increased after 10 min, 20 min and 30 min of FA-AAT. A remnant effect was noted up to 10 min after exposure. This short post-viewing time period could be useful in clinical practice to perform certain painful procedures in children, such as those involving needles, under improved conditions immediately after aquarium exposure. CONCLUSIONS: In the authors' department, FA-AAT is now used as a nonpharmacological antinociceptive technique in association with a protocol of inhalated oxygen/nitrous oxide mixtures for needle-related procedures. Children and parents are invited to watch the aquarium during the 10 min to 20 min before venous punctures.

Influence of the bending of the tip of elastic stable intramedullary nails on removal and associated complications in pediatric both bone forearm fractures: a pilot study.

OBJECTIVES: Both bone forearm fractures are efficiently treated by elastic stable intramedullary nail (ESIN). According to the original technique, the tip of the nail must be bent at 90° and buried under the skin. However, skin irritation is commonly reported and may lead to early surgery to shorten the tip or remove the hardware. The purpose of this study was to investigate the influence of the bending of the tip of the nail in this procedure. METHODS: We retrospectively reviewed 72 children operated on using this technique with the tip bent either at 90° or at 180°. In both groups we recorded complication rates after the procedure and at the removal. RESULTS: Time until removal and duration of the removal were similar in both groups. Three complications (6.7%) that required additional surgery were recorded when the tip was bent at 90° whereas no complications were found with the tip bent at 180°. CONCLUSION: We advocate bending the tip of the nail at 180° before burying it in order to avoid skin irritation and additional procedures. LEVEL OF EVIDENCE: Level III­retrospective comparative study.