RESUMO
BACKGROUND: An area of enlargement of the metaphyseal socket around the epiphyseal tubercle, termed the peritubercle lucency sign, has recently been introduced as a possible predictor of contralateral slipped capital femoral epiphysis in patients with previous unilateral slipped capital femoral epiphysis. This study aimed to assess intraobserver and interobserver reliability for detecting the presence or absence of the peritubercle lucency sign. METHODS: Thirty-five radiographs were presented to 6 fellowship-trained pediatric orthopaedic surgeons on 2 separate occasions 30 days apart, ensuring that the images were shown in a different order on the second exposure. Both times the reviewers recorded whether the peritubercle lucency sign was present or absent in each of the radiographs. Statistical analysis was performed to determine the intraobserver and interobserver reliability. RESULTS: In the intraobserver analysis, percent agreement between the first and second time the radiographs were reviewed varied between 62.9% and 85.7%, for an average intraobserver agreement of 74.8%. κ values for the 6 reviewers varied between 0.34 and 0.716, with an average intraobserver κ value of 0.508. The interobserver percent agreement was 40.0% for the first time the radiographs were reviewed, 42.9% the second time, and the overall interobserver percent agreement was 29%. The interobserver κ value was 0.44 the first time the radiographs were reviewed, 0.45 the second time, and the overall interobserver κ value was 0.45. DISCUSSION: On the basis of our findings, the peritubercle lucency has modest intraobserver and interobserver reliability at best and should be used with other currently used factors, such as age, presence of endocrinopathy, status of triradiate cartilage, posterior sloping angle, and modified Oxford score, in determining the need for prophylactic pinning. Further refinement of the definition of the peritubercle lucency sign may be needed to improve agreement and reliability of the sign. LEVEL OF EVIDENCE: Level III-prognostic study.
Assuntos
Escorregamento das Epífises Proximais do Fêmur/diagnóstico por imagem , Epífises , Humanos , Variações Dependentes do Observador , Radiografia/estatística & dados numéricos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. METHODS: A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. RESULTS: Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. CONCLUSIONS: Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes. LEVEL OF EVIDENCE: Level III-systematic review of level III/IV studies.
Assuntos
Fraturas Intra-Articulares/epidemiologia , Traumatismos do Joelho/epidemiologia , Osteocondrose/epidemiologia , Fraturas da Tíbia/epidemiologia , Adolescente , Síndrome do Compartimento Anterior/epidemiologia , Criança , Comorbidade , Feminino , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Humanos , Articulação do Joelho , Masculino , Redução Aberta/métodos , Ligamento Patelar/lesões , Complicações Pós-Operatórias/epidemiologia , Amplitude de Movimento Articular , Traumatismos dos Tendões/epidemiologia , Fraturas da Tíbia/cirurgia , Lesões do Menisco Tibial/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012. METHODS: From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. RESULTS: A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P<0.0001). Significantly fewer fractures were treated with closed reduction alone in 2012 than in 1997 in age groups 5 to 9, 10 to 14, and 15 to 17 years. Children aged 5 to 9 had more frequent open reduction and internal fixation in 2012 than in 1997, whereas adolescents aged 15 to 17 had less frequent open reduction and internal fixation in 2012 than in 1997. CONCLUSIONS: Although the number of femoral shaft fractures overall has decreased, the frequency of operative treatment has increased significantly in patients 5 to 9 years of age. Knowledge of these trends can guide educational efforts and resource allocation, but further study is necessary to determine procedure-specific (eg, nailing, plating, external fixation) trends and their clinical and economic impacts. LEVEL OF EVIDENCE: Level III-case series.
Assuntos
Tratamento Conservador , Fraturas do Fêmur , Fixação de Fratura , Adolescente , Distribuição por Idade , Pré-Escolar , Tratamento Conservador/métodos , Tratamento Conservador/tendências , Bases de Dados Factuais , Feminino , Fraturas do Fêmur/classificação , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/cirurgia , Fixação de Fratura/métodos , Fixação de Fratura/tendências , Humanos , Recém-Nascido , Pacientes Internados/estatística & dados numéricos , Classificação Internacional de Doenças , Masculino , Pediatria/métodos , Pediatria/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
To compare clinical and radiographic outcomes of medial epicondylar fractures treated operatively to those treated nonoperatively, 30 patients with 31 fractures were divided into three groups: (a) nondisplaced, six treated nonoperatively; (b) incarcerated fragment, four with operative treatment; and (c) displaced but not incarcerated, 21 fractures, 14 treated operatively and seven nonoperatively. Clinical outcomes were assessed with follow-up examination and the Japanese Orthopaedic Association elbow assessment score. Average elbow scores were 98 in nondisplaced fractures, 94 with an incarcerated fragment, 95 in displaced fractures treated operatively, and 94 in displaced fractures treated nonoperatively. The only nonunion was in a fracture with an incarcerated fragment. Both operative and nonoperative treatment produced good outcome scores in displaced but not incarcerated fractures, but radiographic deformity and instability were more frequent in those treated nonoperatively.
Assuntos
Moldes Cirúrgicos , Articulação do Cotovelo/diagnóstico por imagem , Fixação Interna de Fraturas/métodos , Fraturas do Úmero/terapia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Fixação de Fratura/métodos , Fraturas não Consolidadas , Humanos , Fraturas do Úmero/diagnóstico por imagem , Masculino , Radiografia , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Spiral fractures of long bones have long been cited as indications of non-accidental trauma (NAT) in children; however, fracture types are only loosely defined in the literature, and intraobserver and interobserver variability in defining femoral fracture patterns is rarely mentioned. We sought to determine reliability in classifying femoral fractures in young children using a standard series of radiographs shown to physicians with varied backgrounds and training and to determine if a quantitative approach based on objective measurements made on plain radiographs could improve definition of these fractures. METHODS: On 50 radiographs, the fracture ratio--fracture length divided by bone diameter--was determined and radiographs were reviewed by 14 observers, including pediatric orthopaedic surgeons, emergency room physicians, and musculoskeletal radiologists, who classified the fractures as transverse, oblique, or spiral. A second review of the images in a different order was carried out at least 10 days after the first. RESULTS: Overall, intraobserver agreement was strong, whereas interobserver reliability was moderate. Experience level did not correlate with either result. Complete agreement among all observers occurred for only 5 fractures: 3 transverse and 2 spiral. An average fracture ratio near 1.0 appeared to be predictive of a transverse fracture and a ratio of >3.0, a spiral fracture; ratios between these 2 values resulted in essentially random classification. CONCLUSIONS: The ability to reproducibly classify femoral fractures in young children is highly variable among physicians of different specialties. These results support the belief that fracture morphology has little predictive value in NAT because of the wide variability in what observers classify as a spiral fracture of the femur. Caution should be used in the use of descriptive terms such as spiral, oblique, or transverse when classifying femoral fractures, as well as when evaluating children for possible NAT, because of the variability in classification. LEVEL OF EVIDENCE: Level III-diagnostic study.
Assuntos
Fraturas do Fêmur/classificação , Fraturas do Fêmur/diagnóstico por imagem , Médicos/normas , Pré-Escolar , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Radiografia , Reprodutibilidade dos Testes , Método Simples-CegoRESUMO
Orthopedic surgery in the United States has gone through many changes over the past few centuries. Starting with a small sect of subspecialized surgeons, advances in technology and surgical skills have paralleled the growth of the specialty. To keep up with demand, the training of orthopedic surgeons has undergone many iterations. From apprenticeships to the current residency model, the field has always adapted to ensure the constant production of well-trained surgeons to take care of the growing orthopedic needs in the population. In order to guarantee this, many regulatory committees have been formed over the years to help guide the regulation and certification of orthopedic training programs. With current day residents facing new challenges, the specialty continues to adapt the way it trains its future.
Assuntos
Doenças Musculoesqueléticas , Procedimentos Ortopédicos , Cirurgiões Ortopédicos , Ortopedia , Estados Unidos , Humanos , GranzimasRESUMO
BACKGROUND: Femur fractures account for 1.4% to 1.7% of all pediatric fractures. The use of the Pavlik harness has been described for infants; however, previous reports have included only short-term follow-up. This study describes the multiyear clinical and radiographic results from patients younger than 6 months of age treated with a Pavlik harness. METHODS: The clinical and radiographic records were reviewed for all children under the age of 6 months who were treated with a Pavlik harness for an isolated femoral shaft fracture at a level 1 pediatric trauma center. Radiographs were obtained at final follow-up, as well as a standing full-length anteroposterior scanogram. Clinical examination was completed and inquiry regarding patient activity limitations, complications of treatment, and overall parent/provider satisfaction was made. RESULTS: Ten patients with 10 fractures met inclusion criteria. The average age of the patients at the time of injury was 2.2 months. The average duration of Pavlik harness treatment was 43 days (range, 31 to 54 d). The average age at final follow-up was 5.2 years (range, 2.6 to 7.3 y). At final follow-up, average angulation was 3 degrees valgus (range, 0 to 8 degrees) and 5 degrees procurvatum (range, 0 to 24 degrees). Only 1 patient had a measurable leg-length discrepancy of 7 mm at final follow-up. There were no complications noted. CONCLUSIONS: It is felt that pediatric patients have a significant potential for bone remodeling and that any angulation at the time of fracture union will remodel. Our study supports this notion as the final angulation at follow-up averaged 3 degrees valgus and 5 degrees procurvatum. In the patient group presenting with >20 degrees of angulation at the time of injury, final angulation averaged 5 degrees valgus and 11 degrees procurvatum. Treatment with the Pavlik harness provides for excellent clinical outcomes with a minimal complication rate. However, some patients, especially those presenting with a high degree of angulation, may have some degree of persistent radiographic angulation.
Assuntos
Fraturas do Fêmur/terapia , Aparelhos Ortopédicos , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Pais/psicologia , Satisfação do Paciente , Radiografia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The medial ulnar collateral ligament (MUCL) is the primary stabilizer against valgus stress on the elbow. The anatomy of the 3 bundles of the MUCL has been well studied in adults, but our review of the English literature found no study evaluating the origin of the MUCL in a large group of asymptomatic, skeletally immature elbows as it relates to the medial epicondylar physis. METHODS: Magnetic resonance T1-coronal images of 44 skeletally immature elbows (ages 5 to 17 y) with no history of fracture were evaluated by 2 independent musculoskeletal radiologists, a board-certified orthopaedic surgeon with fellowship training in pediatric orthopaedics, and an orthopaedic surgery resident. The location of the origin of the anterior bundle of the MUCL (aMUCL) was identified and its distance from the medial epicondylar physis was measured. RESULTS: All 44 images showed that the aMUCL attached either on or medial to the medial epicondylar physis. The average distance from the origin of the aMUCL to the medial epicondylar physis was 3.1 mm. There was no statistically significant relationship between age and location of the aMUCL insertion relative to the physis (P=0.183). CONCLUSIONS: In the skeletally immature elbow, the aMUCL originates medial to the medial epicondylar physis. CLINICAL RELEVANCE: Although treatment of medial epicondylar humeral fractures remains controversial, understanding the relationship between the aMUCL and the medial epicondylar physis may be helpful in making decisions regarding fracture management.
Assuntos
Ligamentos Colaterais/anatomia & histologia , Imageamento por Ressonância Magnética/métodos , Ulna/anatomia & histologia , Adolescente , Criança , Pré-Escolar , Articulação do Cotovelo/anatomia & histologia , Feminino , Humanos , MasculinoRESUMO
Anecdotal evidence suggests that temporal and environmental factors may contribute to the variance in the volume of pediatric orthopaedic injuries (POI), and knowing the effect of these factors could help in the allocation of resources and personnel in pediatric emergency rooms. All POI presenting to a level 1 pediatric emergency department over a 3-year period were reviewed. Environmental data, including minimal, maximal, and average daily temperatures; amount of precipitation; and lunar phase, were obtained for the study region, as were day of the week and month and season of the year. Multiple logistic regression determined which variable or combination of variables might affect the rate of POI. In the 6770 POI seen over the study period (average 6.2 per day), the day of the week and lunar phase had no effect on the rate of POI, the presence of precipitation lowered the rate slightly, and temperature had a dramatic effect, with the highest number of injuries occurring in the average daily temperature range of 70° to 79°. Winter months of November through February had the lowest rates of POI, while May had the highest.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Meio Ambiente , Fraturas Ósseas/epidemiologia , Pediatria/estatística & dados numéricos , Criança , Humanos , Modelos Lineares , Tennessee/epidemiologiaRESUMO
BACKGROUND: Although flexible intramedullary nailing is a popular treatment option for femoral shaft fractures in juvenile and young adolescent patients, it may not be appropriate in some patients because of patient size and/or fracture configuration. METHODS: Retrospective review over a 3-year period identified 17 skeletally immature patients (18 fractures) with femoral shaft fractures treated with noncannulated rigid locked intramedullary nailing because of a length-unstable fracture or patient overweight or obesity. The 14 males and 3 females had an average age of 10 years at the time of injury (range, 7.6 to 11.9 y). Their average weight was 38.3 kg (range, 22.7 to 52 kg), with an average body mass index of 18.9 (range, 13.9 to 26.9). RESULTS: All fractures united at an average of 13 weeks, with no osteonecrosis, malalignment, malunion, or hardware failure. CONCLUSIONS: Preliminary results suggest that noncannulated, rigid, locked intramedullary nails can be used safely and effectively for selective fixation of femoral shaft fractures in skeletally immature patients younger than 12 years of age. LEVEL OF EVIDENCE: Level IV.
Assuntos
Pinos Ortopédicos , Fraturas do Fêmur/cirurgia , Fixação Intramedular de Fraturas/métodos , Criança , Feminino , Fraturas do Fêmur/patologia , Seguimentos , Fixação Intramedular de Fraturas/efeitos adversos , Fixação Intramedular de Fraturas/instrumentação , Consolidação da Fratura , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Tibial tuberosity fractures have been described as uncommon injuries, but their frequency appears to be increasing. Because of the relatively few cases reported in the literature, little is known regarding risk factors for complications. In a large group of adolescents with tibial tuberosity fractures, we noted more frequent complications in patients who had posterior metaphyseal fractures in addition to tibial tuberosity avulsion fractures. The purpose of this study was to examine the outcomes associated with this fracture pattern and compare them with tibial tuberosity fractures without the posterior component. METHODS: All patients who had closed or open reduction and internal fixation of a tibial tuberosity fracture between January 2003 and December 2010 were identified. All radiographs and medical records were reviewed. RESULTS: Fifty-three tibial tuberosity fractures had radiographs available for review; 15 (28%) fractures had a posterior component identified by either radiograph or computed tomography scan. Four of these combined injuries had an adverse event: 1 patient had compartment syndrome affecting all 4 compartments and 3 patients had refractures after closed reduction and casting. None of the 38 tibial tuberosity fractures without a posterior metaphyseal component had these complications. All patients had complete fracture healing and had returned to full activity at last follow-up. CONCLUSIONS: In this study, a posterior metaphyseal fracture associated with a tibial tuberosity fracture was a marker for potential complications. If radiographs suggest that a fracture line extends through the posterior metaphysis, computed tomography imaging is recommended to confirm the fracture pattern. Open reduction and internal fixation that includes both the anterior and posterior fragments is recommended for all fractures with these combined components, including nondisplaced fractures, because of an increased risk of refracture. LEVEL OF EVIDENCE: Level IV (case study).
Assuntos
Síndromes Compartimentais/etiologia , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Fraturas da Tíbia/complicações , Adolescente , Criança , Síndromes Compartimentais/epidemiologia , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fraturas da Tíbia/patologia , Fraturas da Tíbia/cirurgia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this review was to determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care. METHODS: Retrospective chart review of patients initially seen in a busy urban pediatric orthopaedic clinic identified those who had an ER visit because of a cast-related problem over a 5-year period. Patients were included only if they were seen for their initial visit and cast application in our fracture clinic. RESULTS: Of 168 ER visits made by 155 children treated with cast immobilization, 29% were because of a wet cast; 10%, a damaged cast; 23%, a tight cast; 13%, a loose cast; and 10%, pain. In addition to wet and damaged casts, compliance issues included a missed clinic appointment (5%) and being told by medical personnel to return to the ER for a cast check (8%). Several groups with a high risk for return to the ER were identified: the younger the patient, the more likely that the cast was too loose or wet, and the older the patient, the more likely the cast was too tight. Cast type also played a role: a significantly higher rate of return to the ER was found with long arm, long leg, and hand casts. There were no major complications and no child required hospitalization. CONCLUSIONS: All 168 ER visits required only a cast change or reassurance, which could have been done during regular fracture clinic hours; no child required hospitalization or surgery. From these results, a program has been instituted that includes patient education, triage, and follow-up in our fracture clinics to not only improve the quality of patient care but to decrease the financial burden on physicians and the healthcare system. LEVEL OF EVIDENCE: Economic and decision analysis, Level III.
Assuntos
Moldes Cirúrgicos/efeitos adversos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Fraturas Ósseas/cirurgia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados UnidosRESUMO
Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.
Assuntos
Pinos Ortopédicos , Fraturas do Fêmur/cirurgia , Criança , Redução Fechada , Técnicas de Apoio para a Decisão , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Humanos , Escala de Gravidade do Ferimento , Masculino , Redução AbertaRESUMO
Heterotopic ossification is bone formation that occurs in an abnormal soft tissue location, most commonly after trauma, head injury, and surgical procedures such as joint arthroplasty. We report a rare case of severe heterotopic ossification caused by nonaccidental injury in a 3-year-old child. To our knowledge, heterotopic ossification as a result of nonaccidental injury in children has been reported in only 2 other patients. Physicians should be aware of this rare presentation of nonaccidental injury, and nonaccidental injury should be considered in the differential diagnosis in children who present with heterotopic ossification.
Assuntos
Anquilose/etiologia , Maus-Tratos Infantis/diagnóstico , Articulação do Quadril/patologia , Ossificação Heterotópica/etiologia , Pré-Escolar , Humanos , Masculino , Traumatismo Múltiplo , Músculo Esquelético/patologia , Ossificação Heterotópica/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Progressive valgus deformity after proximal tibial metaphyseal fractures in pediatric patients has been well described, although the pathophysiology is not clear. We performed a retrospective study to evaluate the occurrence of progressive tibia valga after curettage of benign bone lesions of the tibia. METHODS: During a 6-year period, we performed curettage and bone grafting of benign bone lesions of the tibia in 20 patients aged 16 years and younger. Radiographs and clinical notes were reviewed. The diagnosis, age, sex, location of lesion, surgical approach, physeal arrest, limb-length discrepancy, deformity, and treatment were documented. RESULTS: Four patients subsequently developed progressive tibia valga (mean, 12 degrees; range, 7-21 degrees). Progressive valgus deformity occurred in 4 of 5 patients younger than 10 years old who had curettage of lesions of the proximal tibial metaphysis. Deformity did not occur in any of the 13 patients older than 10 years (range, 13-16 years) or in any of the 8 patients who had curettage of the distal tibia (age range, 6-14 years). In patients who developed tibia valga, the deformity progressed during the first 6 to 17 months postoperatively and then stabilized. One patient required corrective osteotomy at age 12 years for a symptomatic 21-degree deformity 3 years after curettage. The other 3 patients with tibia valga remained asymptomatic and demonstrated partial correction of their deformities, currently ranging from 3 to 7 degrees with a mean follow-up of 31 months (range, 19-47 months). CONCLUSIONS: Progressive tibia valga seem to be relatively common in patients younger than 10 years who have had curettage of the proximal tibial metaphysis. This potential sequela should be discussed thoroughly with the patient's parents before proceeding with surgery, and patients should be followed and evaluated for this postoperatively.
Assuntos
Mau Alinhamento Ósseo/etiologia , Curetagem/efeitos adversos , Tíbia/crescimento & desenvolvimento , Fraturas da Tíbia/complicações , Adolescente , Fatores Etários , Mau Alinhamento Ósseo/diagnóstico por imagem , Criança , Pré-Escolar , Progressão da Doença , Feminino , Seguimentos , Lâmina de Crescimento/patologia , Lâmina de Crescimento/cirurgia , Humanos , Desigualdade de Membros Inferiores/diagnóstico por imagem , Desigualdade de Membros Inferiores/etiologia , Masculino , Radiografia , Estudos Retrospectivos , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Fatores de TempoRESUMO
The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.
Assuntos
Traumatismos do Antebraço/terapia , Instabilidade Articular/etiologia , Fraturas do Rádio/terapia , Fraturas da Ulna/terapia , Adolescente , Moldes Cirúrgicos , Criança , Pré-Escolar , Redução Fechada , Diáfises/fisiopatologia , Diáfises/cirurgia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Fraturas do Rádio/fisiopatologia , Reoperação/estatística & dados numéricos , Fatores de Risco , Falha de Tratamento , Fraturas da Ulna/fisiopatologiaRESUMO
Fractures of the hip are uncommon in children, and their importance is related not to the frequency of the injury but to the frequency of complications. Many of these complications can be minimized or avoided by anatomic reduction and internal fixation. Open reduction frequently is necessary to obtain a stable, anatomic reduction. Regardless of the age of the child, stable fixation of the fracture must be given priority over preservation of the proximal femoral physis. The development of osteonecrosis, however, is most likely related to the severity of the initial injury and is largely unaffected by treatment of the fracture.
Assuntos
Fraturas do Quadril/cirurgia , Parafusos Ósseos , Moldes Cirúrgicos , Criança , Descompressão Cirúrgica , Necrose da Cabeça do Fêmur/diagnóstico , Necrose da Cabeça do Fêmur/etiologia , Necrose da Cabeça do Fêmur/terapia , Fixação Interna de Fraturas , Fraturas do Quadril/classificação , Fraturas do Quadril/complicações , Fraturas do Quadril/diagnóstico por imagem , Articulação do Quadril/diagnóstico por imagem , Humanos , Radiografia , Resultado do TratamentoRESUMO
We conducted a study to determine the general level of knowledge that orthopedic residents have on business and practice management topics at graduation and to evaluate the level of knowledge that practicing orthopedic surgeons need in order to function effectively in a medical practice. Residency graduates from a single training program were asked to complete a survey that gathered demographic information and had surgeons rate their understanding of 9 general business and practice management skills and the importance of these skills in their current practice situation. The amount of necessary business knowledge they lacked at graduation was defined as a functional knowledge deficiency (FKD) and was calculated as the difference between the reported importance of a topic in current practice and the level of understanding of that topic at graduation (larger FKD indicates greater deficiency). Those in physician-managed practices reported significantly higher levels of understanding of economic analytical tools than those in nonphysician-managed practices. There were no other statistically significant differences among groups. Hospital-employed physicians had the lowest overall FKD (4.0), followed by those in academic practices (5.1) and private practices (5.9). Graduating orthopedic surgeons appear to be inadequately prepared to effectively manage business issues in their practices, as evidenced by the low overall knowledge levels and high FKDs.
Assuntos
Internato e Residência , Ortopedia/organização & administração , Gerenciamento da Prática Profissional/organização & administração , Competência Clínica , Currículo , Humanos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Certain fracture configurations, especially spiral fractures, are often thought to be indicative of nonaccidental trauma in children. The purpose of this study was to determine whether femoral fracture morphology, as determined by an objective measurement (fracture ratio), was indicative of nonaccidental trauma in young children. METHODS: Consecutive patients who were three years of age or younger and had a closed, isolated femoral shaft fracture treated at an urban pediatric level-I trauma center between 2005 and 2013 were identified. Anteroposterior and lateral fracture ratios (fracture length/bone diameter) were calculated for each patient by a fellowship-trained pediatric orthopaedic surgeon who was blinded to the patient's clinical history. The presence or absence of a Child Protective Services referral as well as institutional Child Assessment Program evaluations were reviewed. Nonaccidental trauma was deemed to be present, absent, or indeterminate by Child Protective Services or an on-site Child Assessment Program team. To further evaluate and quantify the likelihood of nonaccidental trauma, the criteria of the Modified Maltreatment Classification System were used. RESULTS: Of 122 patients identified, ninety-five met the inclusion criteria for this study. Of these ninety-five, fifty-one (54%) had either a Child Protective Services or a Child Assessment Program consultation because of suspected nonaccidental trauma. Thirteen (25%) were found to have nonaccidental trauma as determined by Child Protective Services or the Child Assessment Program team and seven (14%) had indeterminate Child Protective Services or Child Assessment Program investigations. All thirteen patients with nonaccidental trauma, as well as the seven patients with an indeterminate Child Protective Services or Child Assessment Program investigation, had positive Modified Maltreatment Classification System scores for physical abuse. Patients who had nonaccidental trauma had significantly decreased mean anteroposterior fracture ratios compared with those who had confirmed accidental trauma (p < 0.0001). CONCLUSIONS: The fracture ratio can be helpful to determine fracture morphology and can be used as part of the assessment of a child with suspected nonaccidental trauma. While not diagnostic, the presence of a transverse diaphyseal femoral fracture in a young child should raise the index of suspicion for nonaccidental trauma. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.