Pediatric Lower Extremity Lawn Mower Injuries and Reconstruction: Retrospective 10-Year Review at a Level 1 Trauma Center.

INTRODUCTION: From 2004 to 2013, there were 9341 lawn mower injuries in children under 20 years old. The incidence of lawn mower injuries in children has not decreased since 1990 despite implementation of various different prevention strategies. In this report, the authors review the results of pediatric lawn mower-related lower-extremity injuries treated at a tertiary care referral center as well as review the overall literature. METHODS: A retrospective review was performed at a level 1 trauma center over a 10-year period (2005-2015). Patients younger than 18 years who presented to the emergency room with lower extremity lawn mower injuries were included. RESULTS: Of the 27 patients with lower-extremity lawn mower injuries during this period, the mean age at injury was 5.5 years and Injury Severity Score was 7.2. Most (85%) patients were boys and the predominant type of mower causing injury was a riding lawn mower (96%). Injury occurred in patients who were bystanders in 78%, passengers in 11%, and operators in 11%. Mean length of stay was 12.2 days, and mean time to reconstruction was 7.9 days. Mean number of surgical procedures per patient was 4.1. Amputations occurred in 15 (56%) cases with the most common level of amputation being distal to the metatarsophalangeal joint (67%). Reconstructive procedures ranged from direct closure (41%) to free tissue transfer (7%). Major complications included infection (7%), wound dehiscence (11%), and delayed wound healing (15%). Mean follow up was 23.6 months and 100% of the patients were ambulatory after injury. The subgroup of patients with the most severe injuries, highest number of amputations, and need for overall surgical procedures were patients aged 2 to 5 years. A review of the literature also showed consistent findings. CONCLUSIONS: This study demonstrates the danger and morbidity that lawn mowers present to the pediatric population, particularly children aged 2 to 5 years. Every rung of the so-called reconstructive ladder is used in caring for these children. Increased public awareness is insufficient to decrease the incidence of these injuries. These products should have additional warning labels and meet updated changes to the design of lawn mowers to prevent these mutilating injuries successfully.

An Algorithmic Approach to the Suspected Septic Wrist.

An acutely painful, erythematous wrist can be due to a variety of pathologic processes, including crystalline arthropathy, infection, trauma, osteoarthritis, and systemic disease. The broad differential diagnosis of the inflamed wrist and nonspecific clinical findings make accurate diagnosis challenging. There is no published clinical or laboratory criterion that reliably differentiates septic wrist arthritis from a sterile inflammatory arthropathy. For septic joint patients, long-term results are notably poorer in patients with a delay in treatment, therefore establishing evidenced-based guidelines deserves attention.After a comprehensive literature review, we present evidenced-based guidelines and an algorithm for the management of the patient with an acutely inflamed wrist concerning for septic arthritis.For determining a diagnosis, systemic blood laboratory results are extremely variable and unreliable. Despite the attention given to the diagnostic potential of synovial fluid tests, the literature consistently demonstrates that diagnostic certainty cannot always be ascertained at the time of presentation based on aspiration fluid samples. Additionally, the investigative work does not necessarily end at the discovery of crystals since concomitant infection is a rare but well reported entity.Relative to larger joints, the wrist is far less likely to be infected and is easier to drain of debris, and therefore the empiric management of an inflamed wrist joint should reflect these differences. For treatment of the suspected or confirmed septic wrist, prompt initiation with appropriate antibiotics and drainage of joint purulence is critical to rapid recovery. However, the best strategy to clear the joint space of infectious material is controversial. Although the traditional standard of care is open drainage of a septic joint, a growing body of literature supports that for a septic wrist joint, a less invasive approach with serial aspiration can be equally efficacious with reduced morbidity and quicker recovery. If the wrist fails to improve with daily aspirations, then arthroscopy or open washout is needed.For patients with suspected wrist joint infection or crystalline arthropathy with probable concomitant infection, a reasonable approach is admission for systemic antibiotics and daily arthrocentesis. If the wrist fails to improve or worsens, then surgical treatment may be pursued. This treatment strategy could potentially avoid the morbidity of surgery while ensuring that no septic wrist goes untreated.

Long-Term Outcomes of Pediatric Cranial Reconstruction Using Resorbable Plating Systems for the Treatment of Craniosynostosis.

BACKGROUND: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. METHODS: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. RESULTS: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. CONCLUSIONS: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.

Recurrent Atypical Fibroxanthoma Versus Malignant Fibrous Histiocytoma.

Atypical fibroxanthoma (AFX) has been characterized variously as a benign noninvasive neoplasm with rare recurrence. We report 2 cases of recurrent AFX. There is ongoing controversy over the diagnosis of AFX versus malignant fibrous histiocytoma (MFH) in the clinical context of recurrent AFX. Histopathologic diagnosis of fibrohistiocytic neoplasms can be quite challenging and small foci of cancer can be easily overlooked. This is particularly problematic when scarring associated with recurrent tumors is present. The utility of en face sections, as utilized in Mohs micrographical surgery, and the employment of immunohistochemical stains may be helpful in diagnosis. Recurrence of AFX can occur but is difficult to distinguish from MFH.

Management of Severe Microstomia in a Ten-Week-Old Infant.

Microstomia is rarely seen in pediatric patients, but usually results from burns, trauma, or caustic ingestions. There have been multiple studies reporting various techniques for oral commissure reconstruction, but few reports in infants. The authors present another modification of previous techniques of microstomia repair performed in a 10-week-old infant using multiple z-plasties and bilateral mucosal rhomboid flaps.

Argenta clinical classification of deformational plagiocephaly.

INTRODUCTION: A stratification system is useful in deformational plagiocephaly (DP) to help categorize patients and reproduce a consistent treatment strategy. The Argenta classification is a clinical 5-point scale for unilateral DP and 3-point scale for central DP (CDP). METHODS: A retrospective review was completed for patients with DP and classified using the Argenta clinical classification by plastic surgeons at a tertiary medical center over a 12-year period. RESULTS: In the 4483 patients, type III was the most prevalent DP type (42%) followed by II, IV, I, and V. Within CDP, VIB was the most common (6%) followed by VIA and VIC. Right-sided DP (56.8%) was more common than left-sided (28.3%) and bilateral (20.4%) (P < 0.0001). For treatment, 89.8% used molding helmet therapy, 9.3% used positioning only, and 0.4% used sock hat. Helmet use increased with increasing type to 98% with type V. In CDP, there was a significant increase in helmet use between VIA and VIB, but helmet use decreased in VIC. There was a higher rate of positioning only in types I, II, and VIA, which diminished as severity increased. Deformational plagiocephaly corrected to type I or 0 in 83.5% of the patients with the highest correction rate in type I (90.7%). Mean age of correction was 11.4 months and time to correction was 5.7 months. Both significantly increased with severity of type in the patients with DP but not in those with CDP. CONCLUSIONS: The Argenta classification scale allows reliable evaluation for cranial deformities and may help predict the optimal type duration of treatment.

Deformational plagiocephaly and craniosynostosis: trends in diagnosis and treatment after the "back to sleep" campaign.

BACKGROUND: In 1992, the American Academy of Pediatrics discouraged prone sleeping positions because of its association with sudden infant death syndrome. After this was an increased incidence of deformational plagiocephaly (DP). METHODS: A retrospective review was completed for patients with DP and craniosynostosis seen by plastic surgeons at a tertiary medical center during a 19-year period. Two groups of patients were evaluated before (1988-1995) and after (1996-2007) implementation of the "Back to Sleep" campaign. RESULTS: Of the 5169 patients, those with craniosynostosis (n = 279) had a mean age at initial evaluation before and after 1996 of 12.4 versus 5.6 months (P = 0.0008). There was a trend of decreasing age at initial evaluation and first surgery after 1996. For patients with DP (n = 4890), the mean age at initial evaluation before and after 1996 was 11.5 versus 6.0 months (P = 0.10). There was a trend of decreasing age at initial evaluation and DP correction after 1996. The majority of patients had right-sided DP (50.2%), followed by left-sided (24.7%) and bilateral (18.9%). There was no significant difference in DP correction rate (67% versus 87%) or the mean age that DP was corrected (12.8 versus 11.8 mo) before and after 1996. Compared with 1996 to 1999, there was a 214% and 390% increase in DP referrals from 2000 to 2003 and 2004 to 2007. For craniosynostosis, there was a 27% and 129% increase in referrals. CONCLUSIONS: The increasing incidence of DP since the Back to Sleep campaign is concerning, but a positive outcome is that patients are being referred and treated at a younger age.