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Braga Silva J. Fingernail injury in children. HAND SURGERY & REHABILITATION 2024; 43S:101512. [PMID: 36682538 DOI: 10.1016/j.hansur.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/30/2022] [Accepted: 01/14/2023] [Indexed: 01/22/2023]
Abstract
Injuries to the nail complex are common in children. Most children who present with fingertip trauma have experienced a crush injury, usually from the hinge side of a door and often in the living room. This article reviews the literature on the management of fingertip crush injuries, fractures of the distal phalanx, nail bed injury and subungual hematoma to establish, where possible, best evidence.
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Affiliation(s)
- Jefferson Braga Silva
- Service of Hand Surgery and Reconstructive Microsurgery, Pontifical Catholic University of Rio Grande do Sul Hospital São Lucas, Av. Ipiranga, 6690, Centro Clinico PUCRS, Suite 216, Porto Alegre, RS, 90610-000, Brazil; Hospital Moinhos de Vento, Av. Ramiro Barcelos 910, Porto Alegre, RS, 90035-000, Brazil.
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Kim WG, Laor T, Jarrett DY. Physeal injuries of the clavicle: pediatric counterparts to adult acromioclavicular and sternoclavicular joint separations. Pediatr Radiol 2023; 53:1513-1525. [PMID: 36935435 DOI: 10.1007/s00247-023-05617-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 03/21/2023]
Abstract
The epiphyses at the medial and lateral ends of the clavicle are small, ossify relatively late, and may not fuse until early adulthood. Because of this unique anatomy, pediatric and young adult injuries that involve the clavicle often differ from the patterns typically seen in older adults. Clavicular trauma that affects the acromioclavicular joint laterally or sternoclavicular joint medially often results in a physeal fracture and as such, can go unrecognized or be mistaken for a joint dislocation. Radiographic assessment is challenging, particularly when the epiphysis is not yet ossified. However, MR imaging allows for visualization of the cartilage, periosteum and perichondrium, and ligaments of the affected joints. Lateral clavicle physeal injuries can be categorized by the Dameron and Rockwood system, the pediatric correlate to the Rockwood classification of adult acromioclavicular joint injuries. Medial clavicle physeal fractures, similar to adult sternoclavicular joint dislocations, may result in anterior or posterior displacement. Because of their great ability to heal and remodel, clavicular physeal fractures respond better to conservative management than true acromioclavicular or sternoclavicular joint dislocations. Therefore, it is essential to recognize the true nature of these injuries, as there are implications for successful treatment and appropriate prognosis.
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Affiliation(s)
- Wendy G Kim
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tal Laor
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Delma Y Jarrett
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 E. 68Th St., New York, NY, 10065, USA.
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3
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Kamath C, Liu A. Pediatric Musculoskeletal Injuries. Pediatr Ann 2022; 51:e330-e337. [PMID: 36098612 DOI: 10.3928/19382359-20220711-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Musculoskeletal injuries are a common reason for emergency department and primary care visits in the pediatric population. The prevalence of these injuries is likely related to children and adolescents participating in sports activities, physical activity, and exercise that can lead to these injuries. It is important for health care professionals and practitioners to understand the assessment, evaluation, and treatment of musculoskeletal injuries, but also to understand when to refer for expert consultation. [Pediatr Ann. 2022;51(9):e330-337.].
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Kalle JPR, Saris TFF, Sierevelt IN, Eygendaal D, van Bergen CJA. Quality of patient- and proxy-reported outcomes for children with impairment of the upper extremity: a systematic review using the COSMIN methodology. J Patient Rep Outcomes 2022; 6:58. [PMID: 35652989 PMCID: PMC9163282 DOI: 10.1186/s41687-022-00469-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022] Open
Abstract
Background As patient-reported outcome measures (PROMs) have become of significant importance in patient evaluation, adequately selecting the appropriate instrument is an integral part of pediatric orthopedic research and clinical practice. This systematic review provides a comprehensive overview of PROMs targeted at children with impairment of the upper limb, and critically appraises and summarizes the quality of their measurement properties by applying the COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) methodology. Methods A systematic search of the MEDLINE and EMBASE databases was performed to identify relevant publications reporting on the development and/or validation of PROMs used for evaluating children with impairment of the upper extremity. Data extraction and quality assessment (including a risk of bias evaluation) of the included studies was undertaken by two reviewers independently and in accordance with COSMIN guidelines. Results Out of 6423 screened publications, 32 original articles were eligible for inclusion in this review, reporting evidence on the measurement properties of 22 self- and/or proxy-reported questionnaires (including seven cultural adaptations) for various pediatric orthopedic conditions, including cerebral palsy (CP) and obstetric brachial plexus palsy (OBPP). The measurement property most frequently evaluated was construct validity. No studies evaluating content validity and only four PROM development studies were included. The methodological quality of these development studies was either ‘doubtful’ or ‘inadequate’. The quantity and quality of the evidence on the other measurement properties of the included questionnaires varied substantially with insufficient sample sizes and/or poor methodological quality resulting in significant downgrading of evidence quality. Conclusion This review provides a comprehensive overview of currently available PROMs for evaluation of the pediatric upper limb. Based on our findings, none of the PROMs demonstrated sufficient evidence on their measurement properties to justify recommending the use of these instruments. These findings provide room for validation studies on existing pediatric orthopedic upper limb PROMs (especially on content validity), and/or the development of new instruments. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00469-4.
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Affiliation(s)
- J P Ruben Kalle
- Utrecht University, Heidelberglaan 8, 3584CS, Utrecht, The Netherlands.
| | - Tim F F Saris
- Amphia Hospital, Molengracht 21, 4818CK, Breda, The Netherlands
| | - Inger N Sierevelt
- Stichting SCORE, Laarderhoogtweg 12, 1101AE, Amsterdam, The Netherlands
| | - Denise Eygendaal
- Erasmus MC, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
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Weng L, Cao Y, Zhang G, Zhou H, Liu X, Zhang Y. A Comparative Study on Closed Reduction vs. Open Reduction Techniques in the Surgical Treatment of Rotated Lateral Condyle Fractures of the Distal Humerus in Children. Front Pediatr 2022; 10:891840. [PMID: 35722490 PMCID: PMC9201398 DOI: 10.3389/fped.2022.891840] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/04/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The best approach between closed reduction and open reduction in the treatment of total displaced and rotated LCFs is still being debated. This study aimed to comparatively evaluate the clinical outcomes and complications of closed reduction vs. open reduction in the treatment of displaced and rotated lateral condyle fractures in children. Methods We retrospectively evaluated 46 children who underwent surgical treatment for totally displaced and rotated lateral condyle fractures. Thirty-one children underwent open reduction and percutaneous pinning (ORPP). Ten children underwent closed reduction and percutaneous pinning (CRPP). Five children were changed to ORPP procedures because of the failure of closed reduction attempts. Clinical outcomes and complications in the groups were compared. Results Among three groups, no significant differences were found in demographic variables, and no differences were detected in the incidence of postoperative complications and clinical parameters. The ORPP group had the shortest surgical duration of the three groups (p < 0.005). Patients in CRPP group had faster fracture healing than the patients who underwent open reduction procedures. However, the success of CRPP seemed to be dependent on the earlier surgical intervention. Conclusion ORPP is still the first-line treatment for the totally displaced and rotated lateral condyle fractures because of its direct visualization of the joint surface and easy-to-accomplish characteristics. In addition, CRPP may be a feasible option for the treatment of this type of fractures because of it is less invasive and potentially minimizes complications. However, the technical difficulties of CRPP must be taken into account.
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Affiliation(s)
- Liuqi Weng
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yujiang Cao
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ge Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hai Zhou
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xing Liu
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuan Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Goodloe JB, Bailey EP, Luce LT, Corrigan CS, Dow MA, Barfield WR, Murphy RF. A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures. JOURNAL OF SURGICAL EDUCATION 2021; 78:1660-1665. [PMID: 33839079 DOI: 10.1016/j.jsurg.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/03/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set. DESIGN A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure. RESULTS There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)). CONCLUSIONS The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.
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Affiliation(s)
- J Brett Goodloe
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Evan P Bailey
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Lindsay T Luce
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Corinne S Corrigan
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Matthew A Dow
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - William R Barfield
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Robert F Murphy
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina.
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Mlinde E, Amlani LM, May CJ, Banza LN, Chokotho L, Agarwal-Harding KJ. Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi. JB JS Open Access 2021; 6:JBJSOA-D-21-00011. [PMID: 34396025 PMCID: PMC8357253 DOI: 10.2106/jbjs.oa.21.00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting. Methods We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment. Results We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures. Conclusions Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elijah Mlinde
- Department of Orthopedics, Nkhotakota District Hospital, Nkhotakota, Malawi
| | - Lahin M Amlani
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Collin J May
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts.,Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Leonard N Banza
- Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Linda Chokotho
- Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Rubinstein M, Hirway P, Zonfrillo MR. Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures. Pediatr Emerg Care 2021; 37:352-356. [PMID: 33170565 DOI: 10.1097/pec.0000000000002176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury. METHODS We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions. RESULTS A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively). CONCLUSIONS Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.
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Affiliation(s)
| | - Priya Hirway
- Pediatrics, Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, RI
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9
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A quality improvement initiative to reduce cast transitions in a pediatric hospital. J Pediatr Orthop B 2021; 30:405-409. [PMID: 32453120 DOI: 10.1097/bpb.0000000000000753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A quality improvement protocol was implemented in a large tertiary care pediatric hospital to reduce the rate of transitions from emergency department (ED)-applied casts to another form of immobilization (waterproof cast, removable brace, or sling). The local standard of care prior to implementing this quality improvement project involved applying long-arm casts in the ED for children presenting with stable upper extremity injuries (those not requiring a reduction). We created a multidisciplinary quality improvement team with orthopedic and ED providers, as well as cast technicians, with the aim of reducing the transition rate of ED-applied casts in clinic by 50%. Multiple Plan-Do-Study-Act cycles were performed and data were evaluated monthly. Charge fees were determined to assess differences in costs between splints and casts. An independent samples t-test for equality of means was used to determine the ED length of stay of each group. Baseline data determined a cast transition rate of 59.9%. After implementing the quality improvement protocol, the cast transition rate was reduced to 25.0%, a 58% reduction. The length of stay in the ED for a patient receiving a splint as opposed to a cast was 26.2 ± 8.0 min shorter. The charge to a patient receiving a splint rather than an ED-applied cast was $291.25 less. In conclusion, implementation of a multidisciplinary quality improvement protocol resulted in a more than 50% reduction in the transition rate of ED-applied casts in the clinic. Furthermore, healthcare charges to families were reduced by nearly $130 000 annually after implementation of this protocol.
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Evaluation of the effects of ultrasound-guided infraclavicular nerve block on postoperative pain in pediatric supracondylar fracture surgery. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.777247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Management of Pediatric Distal Fingertip Injuries: A Systematic Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2595. [PMID: 32095403 PMCID: PMC7015615 DOI: 10.1097/gox.0000000000002595] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 12/18/2022]
Abstract
Background: Nail bed and fingertip injuries are the commonest hand injuries in children and can lead to profound functional and cosmetic impairments if not appropriately managed. Fingertip injuries can present with subungual hematomas, simple or stellate lacerations, crush, or avulsion injuries, often with associated fractures or tip amputations. The fundamentals of managing nail bed injuries concern restoring the form and function of a painless fingertip. However, there are controversies surrounding the optimal management of each of these injuries, which has led to nonuniformity of clinical practice. Methods: The PubMed database was searched from March 2001 to March 2019, using a combination of MeSH terms and keywords. Studies evaluating children (<18 years of age) and the fingertip (defined as distal to the distal interphalangeal joint) were included following screening by the authors. Results and Conclusion: The evidence base for the diverse clinical management strategies currently employed for fingertip injuries in the pediatric population is limited. Further studies yielding level I data in this field are warranted.
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Matyagin YV, McRobbie DW. Muscle and bone dose in paediatric limb digital radiography: a Monte Carlo evaluation. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 43:10.1007/s13246-019-00820-y. [PMID: 31748969 DOI: 10.1007/s13246-019-00820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/11/2019] [Indexed: 11/24/2022]
Abstract
The proliferation of digital radiography (DR) has led to a re-evaluation of exposure parameters and image quality. Currently, there is a move towards reducing X-ray tube voltage (kVp) in paediatric exposures down to 40 kVp to achieve better images. However, the effect on patient dose of these modifications is uncertain. The main aims of this phantom study were to evaluate the effect of reducing the kVp in paediatric limb DR exposures on contrast-to-noise ratio (CNR) and patient dose. For this purpose, Monte Carlo simulations of radiographic exposures on a paediatric limb phantom were performed. The phantom included muscle tissue and bone segments of five different densities in the range of 1.12 to 1.48 g/cm3. The overall thickness of the phantom varied between 1 and 12 cm. Dependence of the CNR at constant limb phantom muscle and bone doses and dependence of the CNR per unit of muscle and bone dose at constant detector dose on radiographic exposure factors and limb thickness were calculated. X-ray tube current-time product (mAs) values required to achieve equal detector dose versus limb thickness for different kVp were calculated, as well as muscle and bone doses for the limb phantom of varying thickness. Present work has shown that reducing the kVp in paediatric radiography of the extremities can result in a significant increase in radiation dose, particularly for thicker limbs. Low kVp radiography requires justification for use on the extremities.
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Affiliation(s)
- Yuri V Matyagin
- South Australia Medical Imaging, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.
| | - Donald W McRobbie
- South Australia Medical Imaging, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia
- School of Physical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia
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Abstract
Acute onset upper extremity edema can pose a diagnostic challenge for the emergency physician, with conditions ranging from mild local allergic reactions to deep venous thrombosis to underlying life threatening conditions. We discuss a case of a 10-year-old female with upper extremity edema and the diagnostic considerations, which ultimately led to uncovering a malignant etiology. This case represents a rare presentation of her underlying diagnosis, anaplastic large cell lymphoma.
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Webb AL, Slome MC, Walker A, Ganti L. Radial Head Dislocation with Elbow Subluxation in an Adult. Cureus 2019; 11:e5570. [PMID: 31695989 PMCID: PMC6820668 DOI: 10.7759/cureus.5570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Isolated radial head subluxation without fracture, commonly referred to as "nursemaid's elbow," is one of the most common pediatric upper extremity injuries. Radial head dislocation without an associated fracture is rarely seen in adults. They are usually associated with ulnar fractures or an elbow dislocation. We present a case of an adult female presenting with a radial head dislocation and an elbow subluxation sustained while dressing, which was successfully reduced using the techniques commonly used to reduce nursemaid's elbow in pediatric patients.
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Affiliation(s)
- Amanda L Webb
- Emergency Medicine, University of Central Florida College of Medicine / Hospital Corporation of America Graduate Medical Education Consortium of Greater Orlando, Orlando, USA
| | - Mary C Slome
- Emergency Medicine, University of Central Florida College of Medicine / Hospital Corporation of America Graduate Medical Education Consortium of Greater Orlando, Orlando, USA
| | - Ayanna Walker
- Emergency Medicine, University of Central Florida College of Medicine / Hospital Corporation of America Graduate Medical Education Consortium of Greater Orlando, Orlando, USA
| | - Latha Ganti
- Emergency Medicine, Envision Physician Services, Orlando, USA
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Abstract
Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.
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Pirruccio K, Weltsch D, Baldwin KD. Reconsidering the "Classic" Clinical History Associated with Subluxations of the Radial Head. West J Emerg Med 2019; 20:262-268. [PMID: 30881546 PMCID: PMC6404703 DOI: 10.5811/westjem.2019.1.41541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/22/2018] [Accepted: 01/23/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction The national burden of radial head subluxations in the United States (U.S.) population is poorly defined, and non-classical injury mechanisms have been increasingly reported in recent years. The purpose of this study is to report historical national estimates and demographic characteristics of patients presenting to U.S. emergency departments (ED) with subluxations of the radial head. Methods This cross-sectional, retrospective study analyzes the National Electronic Injury Surveillance System (NEISS) database (2001–2017) to identify patients ≤ 7 years of age presenting to U.S. EDs with subluxations of the radial head. Results Linear regression (R2 = 0.65; P < 0.01) demonstrated that the annual number of patients presenting to U.S. EDs with subluxations of the radial head increased significantly (P < 0.001) between 2001 (N=13,247; confidence interval [CI], 9,492–17,001) and 2010 (N=21,723; CI, 18,762–24,685), but did not change significantly between 2010 and 2017 (R2 < 0.01; P = 0.85). It also demonstrated that 51.0% (CI, 45.3%–56.6%) of injuries were either self-induced or spontaneous, whereas 36.8% (CI, 31.6%–42.0%) and 9.4% (CI, 8.0%–10.7%) were associated with parents/guardians or siblings, respectively. The majority of injuries occurred in patients who were the age of one (33.5%; CI, 32.1%–35.0%) and two (35.1%; CI, 33.7%–36.6%); females (57.8%; CI, 56.8%–58.9%) were more commonly injured than males. Conclusion Although the national burden of radial head subluxations may be less than previously reported, it still results in over 20,000 ED visits annually in the U.S. Given that over half of such injuries are actually self-induced or spontaneous, caretakers should be taught to recognize the clinical presentation of radial head subluxation, since the classically described history of a patient being lifted or pulled by the arm may simply have never occurred.
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Affiliation(s)
- Kevin Pirruccio
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Weltsch
- The Children's Hospital of Philadelphia, Division of Orthopaedic Surgery, Philadelphia, Pennsylvania.,Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv-Yafo, Israel.,The Chaim Sheba Medical Center at Tel Hashomer, Department of Orthopaedic Surgery, Tel HaShomer, Ramat Gan, Israel
| | - Keith D Baldwin
- The Children's Hospital of Philadelphia, Division of Orthopaedic Surgery, Philadelphia, Pennsylvania
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17
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Abstract
BACKGROUND Although the recommended treatment for Gartland types I and III supracondylar humeral fractures is well-established, the optimal treatment for type II fractures without rotational malalignment remains controversial, involving circumferential casting or closed reduction and pinning. Our institution uses pronated flexion-taping for Gartland type IIA fractures. This theoretically removes external pressure secondary to circumferential casting, potentially decreasing risks of compartment syndrome and mitigating loss of reduction with extension while maintaining optimal flexion position for reduction. To our knowledge, these modalities have not yet been compared. METHODS A retrospective chart review was performed to compare flexion-taping with cuff-and-collar immobilization versus traditional above-elbow casting at 90 to 100 degrees. It was hypothesized that closed reduction and flexion-taping of type IIA supracondylar fractures under sedation in the emergency department would result in comparable, if not superior, maintenance of reduction measured radiographically using Baumann angle and the lateral humeral capitellar angle (LHCA). Charts from 2010 to 2015 were reviewed for all patients between 2 and 8 years of age with type IIA fractures treated with cast or taping. RESULTS A total of 39 patients were included with 16 in the cast group and 23 in the tape group. Mean age was 4.08±1.72 years across both groups. No significant change in either measure was seen at termination of immobilization (3 to 4 wk postreduction). Final lateral humeral capitellar angle in the taping group was 32.14±5.90 degrees compared with 28.23±7.27 degrees in the casting group (P=0.81). Final Baumann angle was 73.41±4.03 degrees in the taping group compared with 73.75±6.46 degrees (P=0.96). The only complication was a self-limiting rash experienced by 1 patient in the taping group. CONCLUSIONS Both techniques were able to achieve and maintain adequate reduction in all cases with no significant difference in outcome measures. There were no major complications or conversions to surgical treatment. In this cohort, taping resulted in adequate reduction and safe immobilization for type IIA fractures comparable to cast immobilization. Further research will investigate clinical/radiographic outcomes on these patients to assess remodeling and function. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Sahu RL. Percutaneous K wire fixation in pediatric lateral condylar fractures of humerus: A prospective study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lal Sahu R. Percutaneous K wire fixation in pediatric lateral condylar fractures of humerus: A prospective study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:1-7. [PMID: 29157991 DOI: 10.1016/j.recot.2017.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/19/2017] [Accepted: 10/04/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We evaluated the radiographic and clinical functional results of K-wire fixation in the treatment of displaced lateral condyle fractures of the humerus. MATERIALS AND METHODS A prospective longitudinal study was undertaken in our hospital during the period December 2010-December 2014. A total number of 85 children (18 girls and 67 boys) mean age 7.76 years; range 2-13 years with displaced (>2mm) lateral condyle fractures of the humerus. All the patients were treated by close reduction and internal fixation with two K-wires for three weeks. The fractures were classified according to the criteria by Milch and Badelon and functional results were evaluated according to the criteria by Hardacre et al. The mean follow-up period was 24 months (range: 20-28 months). RESULTS All children achieved union in a mean time of 3 weeks (range: 2.5-6 weeks). Functional results were excellent in 91.75% children and good in 7.05% children. Full range of elbow motion was achieved in all the patients. None of the patients had instability postoperatively. Post-operatively, 5.88% children got pin tract infection, which was superficial and healed after removing pins and oral antibiotic administration. CONCLUSION Percutaneous K-wire fixation is an effective treatment for unstable displaced lateral condylar fractures of the humerus in children. If fracture displacement after closed reduction exceeds 2mm, open reduction and internal fixation is recommended.
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Affiliation(s)
- R Lal Sahu
- Department of Orthopedics, School of Medical Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh, India.
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20
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Schwartz BS, Paryavi E, Eglseder WA, Pensy RA, Abzug JM. Brachial Artery Transection After a Closed Traumatic Isolated Medial Epicondyle Fracture in a Pediatric Patient: A Case Report. Hand (N Y) 2017; 12:NP127-NP131. [PMID: 28381125 PMCID: PMC5684950 DOI: 10.1177/1558944717702973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Joshua M. Abzug
- University of Maryland School of Medicine, Baltimore, USA,Joshua M. Abzug, Department of Orthopaedics, University of Maryland School of Medicine, 1 Texas Station, Suite 300, Timonium, MD 21093, USA.
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21
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Roberts SB, Middleton P, Rangan A. Interventions for treating supracondylar fractures of the humerus in children. Hippokratia 2017. [DOI: 10.1002/14651858.cd010131.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Simon B Roberts
- Royal Infirmary of Edinburgh; Department of Trauma and Orthopaedic Surgery; 51 Little France Crescent Old Dalkeith Road Edinburgh Midlothian UK EH16 4SA
| | - Paul Middleton
- Darlington Memorial Hospital/Northern Deanery; Department of Orthopaedics; Darlington UK
| | - Amar Rangan
- The James Cook University Hospital; Marton Road Middlesbrough North Yorkshire UK TS4 3BW
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Joeris A, Lutz N, Blumenthal A, Slongo T, Audigé L. The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF). Acta Orthop 2017; 88:123-128. [PMID: 27882802 PMCID: PMC5385104 DOI: 10.1080/17453674.2016.1258532] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods - We included children and adolescents (0-17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results - Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation - The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.
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Affiliation(s)
- Alexander Joeris
- AO Clinical Investigation and Documentation, Dübendorf;,Department of Pediatric Surgery, Traumatology and Orthopedics, University Hospital (Inselspital) Bern;,Correspondence:
| | - Nicolas Lutz
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne
| | | | - Theddy Slongo
- Department of Pediatric Surgery, Traumatology and Orthopedics, University Hospital (Inselspital) Bern
| | - Laurent Audigé
- AO Clinical Investigation and Documentation, Dübendorf;,Research and Development Department, Schulthess Clinic, Zürich, Switzerland
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Hang BT, Gross C, Otero H, Katz R. An Update on Common Orthopedic Injuries and Fractures in Children: Is Cast Immobilization Always Necessary? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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When is it ok to use a splint versus cast and what remodeling can one expect for common pediatric forearm fractures. Curr Opin Pediatr 2017; 29:46-54. [PMID: 27870687 DOI: 10.1097/mop.0000000000000435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of common pediatric forearm fractures, clarify the descriptions used to identify and thereby appropriately treat them with a splint or cast, and explain osseous remodeling that is unique to the skeletally immature. RECENT FINDINGS Recent literature addresses the gap in standard treatment protocols. There is variability in the management of pediatric forearm fractures because of the multiple subspecialty physicians that care for children's fractures and a lack of well established guidelines. CONCLUSION The following review will expound upon the assortment of pediatric forearm fractures, address suitable treatment options, and illustrate the expected restoration of bony deformity in an effort to update practitioners of the most recent advances in research and clinical practice of this common orthopedic injury.
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Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation. J Pediatr Orthop 2017; 37:7-13. [PMID: 26192878 DOI: 10.1097/bpo.0000000000000579] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. METHODS From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. RESULTS Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). CONCLUSIONS Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. LEVEL OF EVIDENCE Level III-Therapeutic.
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26
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Zhou Y, Teomete U, Dandin O, Osman O, Dandinoglu T, Bagci U, Zhao W. Computer-Aided Detection (CADx) for Plastic Deformation Fractures in Pediatric Forearm. Comput Biol Med 2016; 78:120-125. [PMID: 27684324 DOI: 10.1016/j.compbiomed.2016.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 10/21/2022]
Abstract
Bowing fractures are incomplete fractures of tubular long bones, often observed in pediatric patients, where plain radiographic film is the non-invasive imaging modality of choice in routine radiological workflow. Due to weak association between bent bone and distinct cortex disruption, bowing fractures may not be diagnosed properly while reading plain radiography. Missed fractures and dislocations are common in accidents and emergency practice, particularly in children. These missed injuries can result in more complicated treatment or even long-term disability. The most common reason for missed fractures is that junior radiologists or physicians lack expertise in pediatric skeletal injury diagnosis. Not only is additional radiation exposure inevitable in the case of misdiagnosis, but other consequences include the patient's prolonged uncomfortableness and possible unnecessary surgical procedures. Therefore, a computerized image analysis system, which would be secondary to the radiologists' interpretations, may reduce adverse effects and improve the diagnostic rates of bowing fracture (detection and quantification). This system would be highly desirable and particularly useful in emergency rooms. To address this need, we investigated and developed a new Computer Aided Detection (CADx) system for pediatric bowing fractures. The proposed system has been tested on 226 cases of pediatric forearms with bowing fractures with respect to normal controls. Receiver operation characteristic (ROC) curves show that the sensitivity and selectivity of the developed CADx system are satisfactory and promising. A clinically feasible graphical user interface (GUI) was developed to serve the practical needs in the emergency room as a diagnostic reference. The developed CADx system also has strong potential to train radiology residents for diagnosing pediatric forearm bowing fractures.
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Affiliation(s)
- Yuwei Zhou
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Uygar Teomete
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Ozgur Dandin
- Department of General Surgery, Bursa Military Hospital, Bursa 16800, Turkey
| | - Onur Osman
- Department of Electrical and Electronics Engineering, Istanbul Arel University, Istanbul 34500, Turkey
| | - Taner Dandinoglu
- Department of Physical Medicine and Rehabilitation, Bursa Military Hospital, Bursa 16800, Turkey
| | - Ulas Bagci
- Center for Research in Computer Vision, University of Central Florida, Orlando, FL 32816, USA
| | - Weizhao Zhao
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA; Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Burnier M, Buisson G, Ricard A, Cunin V, Pracros JP, Chotel F. Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases. Orthop Traumatol Surg Res 2016; 102:839-843. [PMID: 27697406 DOI: 10.1016/j.otsr.2016.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/14/2016] [Accepted: 07/27/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Among the various elbow injuries in children that initially have normal radiographs, a certain number of occult fractures are only diagnosed correctly after the fact, during a follow-up visit. PURPOSE This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography. MATERIALS AND METHODS During this prospective study performed between January 1 and April 1 2014, elbow ultrasonography was performed within 6 days in all children under 15 years of age with a suspected occult fracture. The ultrasonography exam looked for lipohemarthrosis, the posterior fat pad sign and cortical disruption. If no fracture was visible on ultrasonography, a removable splint was given to the patient to relieve pain, and no radiological or clinical follow-up was scheduled. The patients were contacted again at least 15 days later to determine whether an undetected fracture was present. Lastly, we evaluated the cost of treatment with and without ultrasonography in the cases where no fracture was diagnosed. RESULTS In 13 cases, ultrasonography revealed lipohemarthrosis and a fat pat sign, with cortical disruption also present in 11 of these cases. In two cases, the diagnosis was made based solely on the presence of lipohemarthrosis and a fat pat sign. There were seven lateral condyle fractures, two medial epicondyle fractures and two supracondylar fractures. Among the 21 patients with normal ultrasonography, no fracture was diagnosed later on. In patients without a fracture, using ultrasonography resulted in a cost savings of €29.10 per patient versus not using it. CONCLUSION In our study, ultrasonography is a sensitive examination for the diagnosis of occult elbow fractures in children. When the radiography and ultrasonography are both normal, the possibility of fracture can be rule out definitively, which reduces the need for immobilization, follow-up and treatment costs. The findings of this preliminary study should be validated with a larger prospective study.
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Affiliation(s)
- M Burnier
- Service de Chirurgie orthopédique, Hôpital Femme Mère Enfant, Lyon, France.
| | - G Buisson
- Service de Radiologie, Hôpital Femme Mère Enfant, Lyon, France
| | - A Ricard
- Service d'Urgences pédiatriques Traumatologiques, Hôpital Femme Mère Enfant, Lyon, France
| | - V Cunin
- Service de Chirurgie orthopédique, Hôpital Femme Mère Enfant, Lyon, France
| | - J P Pracros
- Service de Radiologie, Hôpital Femme Mère Enfant, Lyon, France
| | - F Chotel
- Service de Chirurgie orthopédique, Hôpital Femme Mère Enfant, Lyon, France
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Trends in the volume of operative treatment of midshaft clavicle fractures in children and adolescents: a retrospective, 12-year, single-institution analysis. J Pediatr Orthop B 2016; 25:305-9. [PMID: 26990058 DOI: 10.1097/bpb.0000000000000301] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to examine institutional trends in the volume of clavicle fractures in children and adolescents. Medical records were retrospectively reviewed to identify patients aged 10-18 years treated for a clavicle fracture between 1999 and 2011 at a single tertiary-care pediatric hospital. There were significant increases in the number of clavicle fractures seen annually, of midshaft clavicle fractures, and of midshaft clavicle fractures treated operatively. The percentage of midshaft clavicle fractures treated with fixation also increased significantly. The volumes of clavicle fractures and midshaft clavicle fractures treated operatively appear to be increasing. Despite a lack of evidence-based support, the frequency of fixation of midshaft clavicle fractures appear to be increasing in the pediatric population.
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Margalit A, Stein BE, Hassanzadeh H, Ain MC, Sponseller PD. Percutaneous Screw Fixation of Lateral Condylar Humeral Fractures. JBJS Essent Surg Tech 2016; 6:e15. [PMID: 30237925 DOI: 10.2106/jbjs.st.15.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Lateral condylar humeral fractures are the second most common elbow injury in children and commonly occur between the ages of 5 and 10 years. There are several systems for classification of this fracture, including those of Milch (fracture line location) and Jakob et al. (displacement). Although nonoperative management is indicated for nondisplaced or minimally displaced fractures (<2 mm), operative fixation is indicated for greater displacement. Traditionally, open reduction and internal fixation has been the method used to ensure adequate reduction. However, closed reduction and internal fixation techniques for displaced fractures have been receiving increasing attention, with recent studies showing promising results. Several constructs (multiple smooth pins, a single lag screw, and threaded pins) for closed reduction and internal fixation have been described. Smooth-pin fixation has the advantage of a small diameter and easy removal, whereas threaded pins combine a small diameter with compressive properties. Compression of these small, articular fractures is important, and the optimal mode of fixation for maintaining fracture reduction is debated. Fixation with a partially threaded lag screw works by achieving metaphyseal compression, preventing loss of reduction of the distal fragment. In our experience, the compressive abilities of smooth and threaded pins are limited in the soft osteocartilaginous lateral condyle. Partially threaded lag screw fixation is indicated for pediatric patients with a substantially displaced (Jakob type-II or III) lateral condylar fracture. The major steps of the procedure are (1) preoperative planning with anteroposterior, lateral, and oblique radiographs; (2) supine positioning of the patient with the shoulder in abduction; (3) closed reduction with manual pressure; (4) guide-pin insertion through the lateral column of the distal part of the humerus; and (5) exchange of the guide pin with a lag screw. Postoperatively, the elbow is immobilized with a bivalved long-arm fiberglass cast or a posterior splint. The cast or splint is removed after interval healing is demonstrated on radiographs, and the lag screw is removed after complete fracture union is demonstrated. Complications are rare, and patients are expected to have decreased infection and open-reduction rates compared those treated with pin fixation.
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Affiliation(s)
- Adam Margalit
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Benjamin Eric Stein
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael C Ain
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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Desai N, Caperell KS. Joint Dislocations in the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Dizdarevic I, Low S, Currie DW, Comstock RD, Hammoud S, Atanda A. Epidemiology of Elbow Dislocations in High School Athletes. Am J Sports Med 2016; 44:202-8. [PMID: 26546303 DOI: 10.1177/0363546515610527] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The elbow is the second most commonly dislocated major joint in the general population. Previous studies that focused on emergency department populations indicate that such injuries occur most frequently among adolescent athletes. PURPOSE To describe the epidemiological rates and patterns of sports-related elbow dislocations in high school athletes. STUDY DESIGN Descriptive epidemiology study. METHODS Sports-related injury data for the 2005-2006 through 2013-2014 academic years from a national convenience sample of high schools participating in the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online [RIO]) were analyzed. RESULTS Certified athletic trainers participating in High School RIO reported 115 of 1246 (9.2%) elbow injuries as elbow dislocations. A total of 30,415,179 athlete exposures (AEs) were reported during the study period, resulting in a dislocation rate of 0.38 per 100,000 AEs. The majority of the dislocations resulted from boys' wrestling (46.1%) and football (37.4%). Elbow dislocation rates were higher in competition than in practice. Also, 91.3% of dislocations occurred in boys' sports. Among both boys (60.4%) and girls (88.9%), the majority of injuries occurred during varsity sports activities. Contact with another person was the most common injury mechanism (46.9%), followed by contact with the playing surface (46.0%). Dislocations more commonly resulted in removal from play for more than 3 weeks (23.4% vs 6.9%, respectively) or medical disqualification (36.9% vs 7.0%, respectively) compared with other elbow injuries. Dislocations were also more likely to result in surgical treatment than other elbow injuries (13.6% vs 4.7%, respectively). CONCLUSION In high school athletes, elbow dislocations result in longer removal from play and are more likely to require surgical treatment than nondislocation-associated elbow injuries. Rates and patterns of elbow dislocations vary by sport. In high-risk sports, focused sport-specific prevention strategies may help to decrease the rates and severity of elbow dislocation injuries.
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Affiliation(s)
| | - Sara Low
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dustin W Currie
- School of Public Health, University of Colorado at Denver, Denver, Colorado, USA
| | - R Dawn Comstock
- School of Public Health, University of Colorado at Denver, Denver, Colorado, USA
| | - Sommer Hammoud
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alfred Atanda
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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Nauta J, Jespersen E, Verhagen E, van Mechelen W, Wedderkopp N. Upper extremity injuries in Danish children aged 6-12, mechanisms, and risk factors. Scand J Med Sci Sports 2015; 27:93-98. [PMID: 26648482 DOI: 10.1111/sms.12617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2015] [Indexed: 01/03/2023]
Abstract
Although injuries to the upper extremity are most costly, the picture of the upper extremity injury problem remains incomplete. This study is the first to describe the etiology and mechanisms of upper extremity injuries in Danish children. A 2.5-year observational prospective cohort study was conducted to record upper extremity injuries in 1048 children. Data were weekly collected by sending a text message. A total of 176 upper extremity injuries were reported (128 acute injuries). Of the acute upper extremity injuries, 55% were sprains, 47% occurred in the hand/wrist, and 53% of cases were caused by a fall. When corrected for exposure to physical activity, this resulted in an acute upper extremity injury incidence density of 0.18 per 1000 h of physical activity. The odds of sustaining an upper extremity injury was higher in the older children (HR: 1.84, 95% CI: 1.10-3.09), a tendency was found suggesting that girls are at increased acute upper extremity risk compared to boys (HR: 1.40 95% CI: 0.97-2.04). The findings that most injuries occur after a fall, that injury risk increases over age and that girls seem to be at increased injury risk provides essential information to guide future childhood injury prevention.
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Affiliation(s)
- J Nauta
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - E Jespersen
- Centre for Research in Childhood Health, Institute of Sports and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - E Verhagen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - W van Mechelen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - N Wedderkopp
- Centre for Research in Childhood Health, Institute of Sports and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark.,Orthopaedic dep. Hospital of Lillebaelt and Institute of Regional Health Services Research, The Sport Medicine Clinic, University of Southern Denmark, Lillebaelt, Denmark
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Scannell BP, Brighton BK, VanderHave KL. Neurological and Vascular Complications Associated with Supracondylar Humeral Fractures in Children. JBJS Rev 2015; 3:01874474-201512000-00002. [PMID: 27490996 DOI: 10.2106/jbjs.rvw.n.00084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Brian P Scannell
- Department of Orthopedic Surgery, Levine Children's Hospital/Carolinas HealthCare System, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204
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Malik S, Khopkar SR, Korday CS, Jadhav SS, Bhaskar AR. Transphyseal Injury of Distal Humerus: A Commonly Missed Diagnosis in Neonates. J Clin Diagn Res 2015; 9:SD01-2. [PMID: 26674760 DOI: 10.7860/jcdr/2015/11619.6715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 07/25/2015] [Indexed: 01/27/2023]
Abstract
Distal humeral physeal injury is a rare entity in newborns. Lack of ossific nuclei of the distal humerus in neonates results in a diagnostic dilemma as the injury is radiologically not visible and is often mistaken as elbow dislocation. Ultrasonography and Magnetic resonance imaging help to clinch diagnosis in the early period where plain radiographs fail to detect this entity. This condition warrants high index of suspicion along with good clinical acumen for early diagnosis and immediate management with closed reduction and immobilization to avoid long term complications. We present a case of delayed diagnosis of distal humeral physeal separation in a neonate which was managed conservatively at our neonatal intensive care unit with a good outcome without functional deformity.
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Affiliation(s)
- Sushma Malik
- Professor, Incharge Neonatology, Division of Neonatology, Department of Pediatrics, TN Medical College & BYL Nair Hospital , Mumbai, India
| | - Samruddhi R Khopkar
- Ex-Resident, Neonatology, Division of Neonatology, Department of Pediatrics, TN Medical College & BYL Nair Hospital , Mumbai, India
| | - Charusheela Sujit Korday
- Associate Professor, Neonatology, Division of Neonatology, Department of Pediatrics, TN Medical College & BYL Nair Hospital , Mumbai, India
| | - Shruti Sudhir Jadhav
- Assistant Professor, Neonatology, Division of Neonatology, Department of Pediatrics, TN Medical College & BYL Nair Hospital , Mumbai, India
| | - Atul R Bhaskar
- Consulting Pediatric Orthopaedic Surgeon, Division of Neonatology, Department of Pediatrics, TN Medical College & BYL Nair Hospital , Mumbai, India
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Factors Associated With Orthopedic Aftercare in a Publicly Insured Pediatric Emergency Department Population. Pediatr Emerg Care 2015; 31:704-7. [PMID: 26414642 DOI: 10.1097/pec.0000000000000562] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Children with public insurance are less likely than children with private insurance to obtain follow-up care after emergency department (ED) care. This study aimed to determine if specific demographic and clinical factors are associated with aftercare compliance in a population of publicly insured pediatric ED patients with orthopedic injuries. METHODS This was a retrospective case-control study of Washington, DC, children aged 0 to 17 years with public insurance discharged with isolated forearm fractures from the Children's National Medical Center ED from 2003 to 2006. Bivariable analyses and multivariable logistic regression were performed to measure the association between sociodemographic variables and failure to follow up. RESULTS Six hundred children met the inclusion criteria. The overall cohort was 63.7% male and 81.7% African American, with a mean age of 8.8 (SE, 0.2) years. Overall, 85.7% of patients went to a follow-up orthopedic appointment, and 68.2% of patients had timely orthopedic follow-up, defined as 14 days or less after discharge from the ED. Treatment with orthopedic reduction (adjusted odds ratio [OR], 2.0 [1.33-2.93]) was positively associated with timely orthopedic follow-up, whereas older age (adjusted OR, 0.9 [0.88-0.97]) was significantly associated with failure to follow up. In the subset of patients who required orthopedic reduction in the ED, older age was significantly associated with failure to follow up (adjusted OR, 0.80 [0.74-0.94]). CONCLUSIONS Mild fracture severity is associated with lack of orthopedic follow-up for patients with public insurance. Older age was associated with lack of follow-up, even in the subgroup with severe fractures. Targeted interventions to improve orthopedic aftercare compliance should focus on older patients with severe forearm fractures.
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Jones A, Ansell C, Jerrom C, Honey ID. Optimization of image quality and patient dose in radiographs of paediatric extremities using direct digital radiography. Br J Radiol 2015; 88:20140660. [PMID: 25816115 PMCID: PMC4628445 DOI: 10.1259/bjr.20140660] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 02/02/2015] [Accepted: 03/26/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the effect of beam quality on the image quality (IQ) of ankle radiographs of paediatric patients in the age range of 0-1 year whilst maintaining constant effective dose (ED). METHODS Lateral ankle radiographs of an infant foot phantom were taken at a range of tube potentials (40.0-64.5 kVp) with and without 0.1-mm copper (Cu) filtration using a Trixell Pixium 4600 detector (Trixell, Morains, France). ED to the patient was computed for the default exposure parameters using PCXMC v. 2.0 and was fixed for other beam qualities by modulating the tube current-time product. The contrast-to-noise ratio (CNR) was measured between the tibia and adjacent soft tissue. The IQ of the phantom images was assessed by three radiologists and a reporting radiographer. Four IQ criteria were defined each with a scale of 1-3, giving a maximum score of 12. Finally, a service audit of clinical images at the default and optimum beam qualities was undertaken. RESULTS The measured CNR for the 40 kVp/no Cu image was 12.0 compared with 7.6 for the default mode (55 0.1 mm Cu). An improvement in the clinical IQ scores was also apparent at this lower beam quality. CONCLUSION Lowering tube potential and removing filtration improved the clinical IQ of paediatric ankle radiographs in this age range. ADVANCES IN KNOWLEDGE There are currently no UK guidelines on exposure protocols for paediatric imaging using direct digital radiography. A lower beam quality will produce better IQ with no additional dose penalty for infant extremity imaging.
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Affiliation(s)
- A Jones
- Medical Physics Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Medical Physics Department, Western Sydney Local Health District, Sydney, NSW, Australia
| | - C Ansell
- Radiology Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Jerrom
- Medical Physics Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I D Honey
- Medical Physics Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Oetgen ME, Mirick GE, Atwater L, Lovejoy JF. Complications and Predictors of Need for Return to the Operating Room in the Treatment of Supracondylar Humerus Fractures in Children. Open Orthop J 2015; 9:139-42. [PMID: 26157530 PMCID: PMC4484238 DOI: 10.2174/1874325001509010139] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/02/2015] [Accepted: 04/12/2015] [Indexed: 12/11/2022] Open
Abstract
Supracondylar humerus fractures are common pediatric injuries. Little is known about the risk factors for repeat operative procedures. A retrospective chart review of 709 patients treated for a displaced supracondylar humerus fracture was performed to identify risk factors for return to the operating room during the initial post-operative period. Deviations of routine fracture care were recorded and complication rates were compared between Gartland type 2 and 3 fractures using logistic regression. Type 3 fractures were found to have a higher complication rate, and, specifically, more peri-operative nerve palsies, more likely to need to return to the operating room for hardware removal, to lose fracture reduction, and require a return to the operating room for any reason. Five risk factors which may require returning to the operating room were identified: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. In conclusion, Gartland type 3 supracondylar humerus fractures are associated with more complications then type 2 fractures. Risk factors for the need to return to the operating room in the post-operative period include: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. Patients with these risk factors should be considered at risk for return to the OR and fracture fixation and follow up protocols should be adjusted for this risk.
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Affiliation(s)
- Matthew E Oetgen
- Department of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC, USA
| | - Gudrun E Mirick
- Department of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC, USA
| | - Lara Atwater
- Department of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC, USA
| | - John F Lovejoy
- Department of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC, USA
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Postoperative pain and the use of ultrasound-guided regional analgesia in pediatric supracondylar humerus fractures. J Pediatr Orthop B 2015; 24:178-83. [PMID: 25569536 DOI: 10.1097/bpb.0000000000000139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
A total of 230 children undergoing closed reduction and percutaneous pinning of supracondylar humerus fractures were analyzed retrospectively. Severe pain (score ≥ 7/10) was reported in 10% of general anesthesia-only patients in the postanesthesia care unit and in 28% of the 130 admitted patients. The 36 patients who received ultrasound-guided regional analgesia+general anesthesia had decreased intraoperative opioid consumption and postanesthesia care unit pain scores. After admission, pain scores and opioid consumption did not differ between fracture and anesthesia types. No patient developed compartment syndrome. Severe pain is frequent after closed reduction and percutaneous pinning of supracondylar humerus fractures. Further study of ultrasound-guided regional analgesia is needed.
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Thornton MD, Della-Giustina K, Aronson PL. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 2015; 33:423-49. [PMID: 25892730 DOI: 10.1016/j.emc.2014.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
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Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
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Separation of the proximal humeral epiphysis in the newborn: rapid diagnosis with ultrasonography. Case Rep Pediatr 2015; 2015:825413. [PMID: 25694841 PMCID: PMC4324951 DOI: 10.1155/2015/825413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 11/18/2022] Open
Abstract
Separation of the proximal humeral epiphysis (SPHE) is a well-known occurrence and may occur secondary to trauma, infection, and nonaccidental trauma. Since most newborns do not have the proximal humeral epiphysis ossified at birth, the diagnosis may be difficult to make on routine radiographs. Ultrasonography of the shoulder in the newborn is rapid, noninvasive, and nonionizing imaging techniques which can diagnose SPHE. In this report, we describe and emphasize the diagnostic utility of state-of-the-art ultrasonography for the diagnosis of SPHE.
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Abstract
BACKGROUND Many pediatric forearm fractures can be treated in plaster following closed reduction. The cast index (CI, a ratio of anteroposterior to lateral internal diameters of the cast at the fracture site) is a simple, reliable marker of quality of molding and a CI of >0.8 correlates with increased risk of redisplacement. Previously, CI has been applied to all forearm fractures. We hypothesize that an acceptable CI is more difficult to achieve and does not predict outcome in fractures of the proximal forearm. MATERIALS AND METHODS Seventynine cases of pediatric forearm fractures initially treated by manipulation alone over a year were included in this retrospective radiographic analysis. The CI was calculated from the post manipulation radiographs. All fractures were divided as either proximal or distal half forearm based on the location of the radius fracture. Subsequent radiographs were reviewed to assess redisplacement and reoperation. RESULTS The mean CI was 0.77. Remanipulation was required in five cases (6%), all distal half fractures - mean CI 0.79. CI was higher in proximal half forearm fractures (0.83 vs. 0.76, P = 0.006), nonetheless these fractures did not re-displace more than distal fractures. CONCLUSION Cast index is useful in predicting redisplacement of manipulated distal forearm fractures. We found that in proximal half forearm fractures it is difficult to achieve a CI of <0.8, but increased CI does not predict loss of position in these fractures. We therefore discourage the use of CI in proximal half forearm fractures.
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Affiliation(s)
- Hassaan Qaiser Sheikh
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds LS1 3EX, UK,Address for correspondence: Dr. Hassaan Qaiser Sheikh, 10 Oldroyd Way, Dewsbury, WF13 2JJ, England. E-mail:
| | - Karan Malhotra
- Department of Trauma and Orthopaedics, York Hospital, York YO31 8HE, UK
| | - Phil Wright
- Department of Trauma and Orthopaedics, Bradford Royal Infirmary, Bradford BD9 6RJ, UK
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Abstract
BACKGROUND There are limited data on the sonographic evaluation of normative physeal plate measurements in healthy, uninjured children. OBJECTIVES This study aimed to determine baseline measurements in physeal plate widths and to assess variation in the measured widths among contralateral sides, age group, and sex in healthy, uninjured children. METHODS This was a prospective observational study of a convenience sample of healthy patients between 0 and 12 years of age presenting to the pediatric emergency department. A point-of-care ultrasound examination of the distal radius, ulna, fibula, and tibia was performed bilaterally (8 total). Measurements were taken at the physeal plates in the longitudinal plane at the widest distance. The degree of variance of physeal plate widths within an individual and the mean values of physeal plate widths for each bone were calculated. RESULTS A total of 95 patients were enrolled in this study. The mean age of the enrolled patients was 6 years 3 months; 40% were female. Mean (SD) physeal plate widths for the averaged measurement of each bone were as follows: radius, 0.32cm (0.09); ulna, 0.31cm (0.09); fibula, 0.31cm (0.08); and tibia, 0.39cm (0.09). Mean (SD) values for the absolute difference in physeal plate widths were as follows: radius, 0.08cm (0.06); ulna, 0.07cm (0.10); fibula, 0.06cm (0.06); and tibia, 0.06cm (0.05). When measurements were stratified by age and sex, the mean physeal plate widths and mean difference in physeal plate widths did not demonstrate any significant differences. CONCLUSIONS This pilot study demonstrated that there was no statistically significant difference in physeal plate widths between contralateral extremities and the degree of variation between contralateral extremities was minimal. Results of this study elucidate normative physeal plate variance in healthy children and demonstrate that mean physeal plate measurements and absolute differences are narrow. This study suggests that sonographic detection of significant disparities in physeal plate widths of injured children may have the potential for earlier detection of Salter-Harris injuries with subsequent appropriate referral and management.
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bin Mohd Fadil MF, Mahadev A, Gera SK. Radial head and neck injuries in children with elbow dislocations: a report of three cases. J Orthop Surg (Hong Kong) 2014; 22:252-6. [PMID: 25163968 DOI: 10.1177/230949901402200230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In children, traumatic elbow dislocations usually occur after the epiphysis has closed and with associated radial head and neck fractures and osteochondral fragments. The fragments are also usually interposed in the joint restricting complete congruent joint motion. We report on 3 children with traumatic elbow fracture-dislocation with associated radial head and neck injuries treated with open reduction and stabilisation. All patients achieved good outcomes and returned to pre-injury level of activities.
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Affiliation(s)
| | - Arjandas Mahadev
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore
| | - Sumanth Kumar Gera
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore
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Rudroff T, Holmes MR, Melanson EL, Kelsey MM. Sex differences in time to task failure during early pubertal development. Muscle Nerve 2014; 49:887-94. [DOI: 10.1002/mus.24076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 08/24/2013] [Accepted: 09/04/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Thorsten Rudroff
- Department of Integrative Physiology; University of Colorado; Boulder Colorado USA
- Department of Health and Exercise Science; Colorado State University; Fort Collins Colorado USA
| | - Matthew R. Holmes
- Department of Integrative Physiology; University of Colorado; Boulder Colorado USA
- Department of Physiology; Northwestern University; Chicago Illinois USA
- Sensory Motor Performance Program; Rehabilitation Institute of Chicago; Chicago Illinois USA
| | - Edward L. Melanson
- Division of Endocrinology, Diabetes, and Metabolism; Colorado USA
- Division of Geriatrics; University of Colorado Denver; Anschutz Medical Campus Aurora Colorado USA
| | - Megan M. Kelsey
- Department of Pediatric Endocrinology; University of Colorado Denver; Anschutz Medical Campus Aurora Colorado USA
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Abstract
OBJECTIVE Hand fractures represent a leading cause of morbidity in children. However, little information exists correlating the mechanisms and environment of injury with outcomes and treatments. We examine the demographics, etiology, anatomic location, mechanism, and management of pediatric hand fractures in our center's hand unit. METHODS We conducted a prospective observational study on all children with acute hand fractures evaluated in the Plastic Surgery Emergency Clinic during a 3-month period in 2010. Data pertaining to demographics, referral patterns, injury pattern, clinical outcomes, and other factors related to hand fractures were then analyzed and interpreted. RESULTS Most children were referred by our institution's emergency department. More than 60% were boys, and nearly half were between 10 and 15 years old. The right and left hands were injured at equal rates. Most of the injuries (90%) occurred in the afternoon or evening. More than 85% occurred in urban, rather than rural, environments. Crush injuries were the leading cause in toddlers, whereas sports-related injuries became the major cause of injury in older groups. Proximal phalanges were the most common bone injured, and the fifth digit was the most commonly injured digit. More than 80% of the fractures were managed nonsurgically. CONCLUSIONS The pattern of pediatric hand fracture in different age groups is highlighted in this article. The observations from this study will hopefully encourage further review with a larger cohort and a focus on preventative measures for pediatric hand fractures.
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Salonen A, Pajulo O, Lahdes-Vasama T, Välipakka J, Mattila VM. Increased incidence of distal humeral fractures and surgical treatment in 0- to 18-year-old patients treated in Finland from 1987 to 2010. J Child Orthop 2013; 7:559-64. [PMID: 24432121 PMCID: PMC3886348 DOI: 10.1007/s11832-013-0529-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 09/03/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Studies of pediatric and adolescent fractures in general report a significant increase in the incidence of upper-extremity fractures as well as in their surgical treatment. The aim of this study was to determine the trends of the incidence and treatment of distal humeral fractures in hospitalized 0- to 18-year-old patients in Finland. METHOD The study included the entire pediatric and adolescent (<19 years) population in Finland during the 24-year period from 1 January 1987 to 31 December 2010. Data on hospitalized patients were obtained from the nationwide National Hospital Discharge Registry where information is collected from all hospital categories (private, public, and other). Surgical treatment was categorized into three groups; (1) reposition with casting; (2) reposition or reduction and osteosynthesis; (3) reposition or reduction and external-fixation and other fixation methods. Patients were classified into three groups according to age: 0-6 years, 7-13 years, and 14-18 years. Annual incidences were calculated using the annual mid-year population census obtained from the Official Statistics of Finland. RESULTS During the 24-year study period, there were a total of 12,590 hospitalizations with a main or secondary diagnosis of distal humeral fracture. In children aged 0-12 years the overall incidence of hospitalization increased 30 % during the 24-year study period, from 4.5 per 10,000 person-years in 1987 to 5.8 per 10,000 person-years in 2010. There were a total of 5,548 operations. During the study period, surgical treatment by repositioning or reduction with osteosynthesis due to a distal humeral fracture increased by fivefold in patients aged <6 years and by twofold in patients aged 7-12 years of age. The incidences of fracture and treatment in children older than 13 years did not change. CONCLUSION The incidence of distal humeral fractures and the incidence of repositioning with osteosynthesis increased remarkably in prepubertal children during the 24-year study period in Finland.
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Affiliation(s)
- A. Salonen
- />Department of Pediatric and Adolescent Surgery, Pediatric Clinics and Pediatric Research Center, Tampere University Hospital, Teiskontie 35, 33521 Tampere, Finland
| | - O. Pajulo
- />Department of Pediatric Surgery, Pediatric Clinics, Turku University Hospital, Turku, Finland
| | - T. Lahdes-Vasama
- />Department of Pediatric and Adolescent Surgery, Pediatric Clinics and Pediatric Research Center, Tampere University Hospital, Teiskontie 35, 33521 Tampere, Finland
| | - J. Välipakka
- />Department of Pediatric and Adolescent Surgery, Pediatric Clinics and Pediatric Research Center, Tampere University Hospital, Teiskontie 35, 33521 Tampere, Finland
| | - V. M. Mattila
- />Division of Orthopedics and Traumatology, Department of Trauma, Musculoskeletal Surgery, and Rehabilitation, Tampere University Hospital, Tampere, Finland , />Department of Orthopedics, Karolinska Hospital, Stockholm, Sweden
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Brooks A, Hammer E. Acute Upper Extremity Injuries in Young Athletes. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2013. [DOI: 10.1016/j.cpem.2013.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Marashi Nejad SA, Mehdi Nasab SA, Baianfar M. Effect of supination versus pronation in the non-operative treatment of pediatric supracondylar humerus fractures. ARCHIVES OF TRAUMA RESEARCH 2013; 2:26-9. [PMID: 24396786 PMCID: PMC3876516 DOI: 10.5812/atr.10570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 03/04/2013] [Accepted: 03/09/2013] [Indexed: 11/16/2022]
Abstract
Background Supracondylar fracture of the humerus is the most common elbow injury that requires reduction and immobilization in the proper position to union. There are a few reports regarding the position of the forearm immobilization on elbow cosmetic outcome. Objectives This study aimed to compare two modes of the forearm, supination and pronation in elbow deformity incidence after closed reduction and casting of this fracture. Patients and Methods This prospective and descriptive study was carried out on children with supracondylar fracture of the humerus treated with closed reduction and cast immobilization in one of the two modes of either supination or pronation for a period of three weeks. Twenty-nine patients were immobilized in supination and 35 in pronation. Follow-up lasted for 8 months. Re-displacement was defined as the criteria and subsequent deformities of the elbow in patients, were assessed by clinical and radiographic examination. Results A total of 64 patients, 50 boys and 14 girls, with the mean age of 4.8 years (3.1 to 8.5 years) participated. All fractures were closed and of the extension type. Forty-five cases had Gartland type II and 19 had type III fracture. Deformity of the elbow had occurred in seven cases (10.94%). Four cases of cubitus varus (CA 5 º - 16º) were observed in the supination group, of these, three patients had type III and one other had a type II fracture. In the pronation group, two cases of cubitus varus (CA 6 º - 14º) and one case of cubitus valgus (CA 17º) were observed, with type III initial fracture in all 3 cases. Conclusions In regard to elbow malunion deformity, no obvious difference was observed between the two methods of supination and pronation in the closed treatment of supracondylar humerus fracture. However, as cubitus varus and valgus had occurred in both groups with unstable type III fractures, to prevent this complication, operative fixation is advised rather than closed reduction and position of the forearm immobilization.
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Affiliation(s)
- Seyed Ali Marashi Nejad
- Department of Orthopedics, Musculoskeletal and Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Seyed Abdolhossein Mehdi Nasab
- Department of Orthopedics, Musculoskeletal and Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
- Corresponding author: Seyed Abdolhossein Mehdi Nasab, Department of Orthopedics, Musculoskeletal and Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran. Tel./Fax: +98-6112921836, E-mail:
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Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care 2013; 29:39-42. [PMID: 23283261 DOI: 10.1097/pec.0b013e31827b52a7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fractures are reported to complicate anterior shoulder dislocations in up to 50% of adults. For this reason, prereduction and postreduction radiographs are recommended for the routine evaluation of shoulder dislocations in all patients. To date, few data have been reported as to the incidence of fractures or as to the value of prereduction x-rays in pediatric patients with anterior shoulder dislocations. OBJECTIVES The objectives of this study were to estimate the incidence of fractures associated with anterior shoulder dislocation in pediatric patients and to examine the value of prereduction radiographs for these patients. METHODS This was a retrospective review of records for pediatric patients who presented to an emergency department (ED), received a diagnosis of anterior shoulder dislocation, and had at least 1 set of shoulder x-rays. RESULTS Of 119 patients who met criteria for inclusion in the study, 3 patients (3%) had a fracture identified; 6 patients (5%) had a possible fracture identified. Except for 1 patient with an avulsion fracture who was transferred without a reduction attempt or further x-rays, all patients had their dislocation reduced uneventfully in the ED. CONCLUSIONS In our sample of pediatric patients with anterior shoulder dislocations due to low-energy injury mechanisms, plain radiography identified a lower incidence of fractures than those reported from adult studies. Pediatric patients with anterior shoulder dislocations clinically apparent after clinical evaluation may not benefit from prereduction radiographs. Forgoing prereduction x-rays might expedite definitive pain relief for patients, lower cost and radiation exposure, and decrease ED length of stay.
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Ng L, Martin JA, Lewiss RE. What are the baseline measurements for physeal plate widths in healthy, uninjured children? Crit Ultrasound J 2012. [PMCID: PMC3524473 DOI: 10.1186/2036-7902-4-s1-a17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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