Assessment of Splints Applied for Pediatric Fractures in an Emergency Department/Urgent Care Environment.

BACKGROUND: Fractures are common in the pediatric population. The initial evaluation is rarely by an orthopaedic surgeon, but commonly an emergency room or urgent care center physician/extender. This typically involves splint application by a nonorthopaedist to immobilize the extremity and provide stabilization. Iatrogenic injuries from inappropriate splint placement are a potential public health and legal concern that can lead to complications. The primary purpose of this study was to prospectively evaluate the adequacy of all splints placed on patients who presented to a pediatric orthopaedic office; secondary outcomes included assessing prevalence and types of complications that were associated with inadequate splints. METHODS: Patients aged 0 to 18 years who presented with a splint were prospectively enrolled. Information was obtained regarding demographics of the patient and splint placement. Splints were evaluated for functional position, appropriate length, and presence of elastic bandage on the skin. Photographs were taken of each splint, and the extremity was examined for any soft tissue complications. Splints were not removed in 31 patients who had undergone fracture reduction. RESULTS: In total, 275 patients were prospectively enrolled. Splints were improperly placed in 93%, with application of elastic bandage directly to the skin accounting for 77%. Improper positioning was observed in 59%, and inappropriate splint length was present in 52%. Skin and soft tissue complications were observed in 40%. The most common iatrogenic splint-related complication was excessive edema, seen in 28%. Direct injury to the skin and soft tissue was seen in 6%. CONCLUSIONS: Many practitioners incorrectly apply splints, potentially leading to suboptimal results or causing injury. Complications of poor splint placement include excessive swelling, skin breakdown, and poor immobilization. Health care workers who treat pediatric fractures may benefit from more extensive education regarding proper splinting techniques. LEVEL OF EVIDENCE: Level 2-therapeutic study.

Reliability and Effectiveness of Smartphone Technology for the Diagnosis and Treatment Planning of Pediatric Elbow Trauma.

BACKGROUND: Mobile imaging, such as viewing radiographs as text messages, is increasingly prevalent in clinical settings. The purpose of this study was to determine whether remote diagnosis of pediatric elbow fractures using smartphone technology is reliable. In addition, this study aimed to determine whether the assessment regarding the decision for operative treatment is affected by evaluation of images on a mobile device as opposed to standard picture archiving and communication system (PACS). METHODS: Standard anteroposterior and lateral radiographs of 50 pediatric elbow trauma cases were evaluated by 2 fellowship-trained pediatric orthopaedic surgeons and 2 senior orthopaedic residents. Raters were asked to classify the case as any of 6 diagnoses: supracondylar humerus, lateral condyle, medial epicondyle, radial neck fracture, positive posterior fat pad sign, or normal pediatric elbow. Raters were asked to choose operative or conservative treatment. After 1 week, photographs of the same images were taken from a standardized distance from a computer monitor with an iPhone 5 camera and transmitted by multimedia messaging to each rater. The same questions were again posed to raters. Interobserver and intraobserver reliabilities were calculated by Cohen κ-statistics with bootstrapped 95% confidence intervals. RESULTS: Intraobserver reliability of classification of injuries on PACS compared with smartphone images was excellent, with an overall κ of 0.91. Treatment decision also demonstrated excellent intraobserver reliability (PACS vs. smartphones) with a κ of 0.86 for all raters. CONCLUSIONS: Diagnosis of pediatric elbow injuries can be made equally reliably based on either PACS or transmitted multimedia messaging images taken with an iPhone camera from a computer screen and viewed on a smartphone. Treatment decisions can also be made reliably based on either image modality. CLINICAL RELEVANCE: Using smartphones to transmit and display radiographs, which is common in current clinical practice, is effective and reliable for diagnosis and treatment planning of pediatric elbow injuries.

Brachial Artery Transection After a Closed Traumatic Isolated Medial Epicondyle Fracture in a Pediatric Patient: A Case Report.

BACKGROUND: Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. METHODS: A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. RESULTS: A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. CONCLUSIONS: Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.