Toddler's fracture: presumptive diagnosis and treatment.

The diagnosis of a toddler's fracture is frequently difficult at the initial evaluation because of negative radiographs. We propose the presumptive diagnosis of toddler's fracture, despite negative radiographs, when the history and physical examination are consistent with the diagnosis. This retrospective study was designed to evaluate how frequently the diagnosis is correct and to determine if there were any differentiating characteristics with respect to history, gait, or physical examination. Thirty-nine children were presumptively diagnosed with toddler's fracture. A total of 16 (41%) toddler's fractures was confirmed on follow-up radiographs. Comparing the children who demonstrated a toddler's fracture with those who did not, no particular characteristic was found that could predict the outcome. To avoid delay in the treatment of toddler's fracture, we recommend a long-leg cast on those children with a history of an acute injury, inability to walk or limp, no constitutional signs, and negative radiographs.

Intramedullary fixation of pediatric forearm diaphyseal fractures.

Surgical treatment of pediatric forearm fractures is controversial. In this retrospective study, we reviewed 24 skeletally immature radial and ulnar fractures in 24 patients treated with intramedullary Rush pins and/or Kirschner wires between 1994 and 1999. The indication for surgical intervention was unacceptable closed reduction, unstable fracture pattern, open fracture, or recurrence after nonsurgical treatment. For each patient, a sugar tong splint was used for 4 weeks, and pins were removed 8 weeks after surgery. Average length of follow-up was 32 months (range, 6-58 months). All fractures in this series healed. Average time to union was 8 weeks. There were no complications of delayed union, nonunion, infection, or neurovascular injury. All patients regained full range of motion of the injured extremity.

Etomidate for pediatric sedation prior to fracture reduction.

OBJECTIVE: While etomidate is reported as a procedural sedative in adults, its use in children has not been extensively reported. The authors describe their experience with etomidate for procedural sedation in children with extremity fractures and major joint dislocations. METHODS: This was a retrospective descriptive chart review. The setting was a university-based emergency department (ED) that follows national guidelines for procedural sedation. Subjects were children less than 18 years old who received etomidate prior to fracture reduction or major joint dislocations. Standardized data were abstracted from the medical records, including patient demographics, diagnosis, weight, types and doses of sedative and analgesic agents used, number of boluses of etomidate, attempts at reduction, complications encountered, vitals signs before, during, and after the reduction, disposition, and the time from procedure to discharge. Descriptive statistics calculated included means and proportions with 95% confidence intervals. RESULTS: Fifty-three children received etomidate for fracture reduction. Their mean age was 9.7; 41.5% were females. Indications for reduction included forearm fractures (38), ankle fractures (12), upper arm fractures (2), and hip dislocations (1). In most cases (83%) reduction was successful after one attempt only. The mean initial and total doses of etomidate were 0.20 mg/kg (range, 0.1 to 0.4) and 0.24 mg/kg (range, 0.13 to 0.52), respectively. Thirteen patients required a second bolus of etomidate or midazolam. Thirty-four patients (64%) were discharged from the ED after a mean observation of 94 minutes (range, 35 to 255). There were no major adverse events (95% CI = 0% to 5.7%). One patient reported nausea and one required a fluid bolus for hypotension. One patient receiving multiple sedatives and opioid analgesics was admitted for observation due to prolonged sedation. No patient required assisted ventilation or intubation. CONCLUSIONS: These results suggest that etomidate is a safe and effective agent for procedural sedation in children requiring fracture and major joint reductions.

Circumferential growth plate fracture of the thoracolumbar spine from child abuse.

We report a unique fracture dislocation of the immature spine associated with child abuse and paraplegia. Because it occurs through growth centers, this fracture may be initially difficult to identify without special studies. The fracture patterns were isolated injuries in both children and were best shown with computer tomography. Mechanisms of injury are proposed and should suggest child abuse as a cause. Experience with these initial cases has suggested a treatment approach based on the mechanism of injury. There is no indirect means of reduction for this fracture and anterior open reduction is the treatment of choice.

Use of parenteral prophylactic antibiotics in clean orthopaedic surgery. A review of the literature.

Parenteral prophylactic antibiotics are now a routine part of most clean orthopaedic procedures since so many animal and clinical studies have shown a reduced infection rate with their use. First-generation cephalosporins are theoretically the preferred agents, and the pharmacokinetics of Cefazolin make it the drug of choice. It is imperative that an antibiotic be given on the induction of anesthesia or at least ten minutes before inflation of a tourniquet. Based on evidence in the current literature, 24 hours of postoperative coverage appears to be adequate.

Laser ranging retro-reflector: continuing measurements and expected results.

After successful acquisition in August of reflected ruby laser pulses from the Apollo 11 laser ranging retro-reflector (LRRR) with the telescopes at the Lick and McDonald observatories, repeated measurements of the round-trip travel time of light have been made from the McDonald Observatory in September with an equivalent range precision of +/-2.5 meters. These acquisition period observations demonstrated the performance of the LRRR through lunar night and during sunlit conditions on the moon. Instrumentation activated at the McDonald Observatory in October has yielded a precision of +/-0.3 meter, and improvement to +/-0.15 meter is expected shortly. Continued monitoring of the changes in the earth-moon distance as measured by the round-trip travel time of light from suitably distributed earth stations is expected to contribute to our knowledge of the earth-moon system.

Laser beam directed at the lunar retro-reflector array: observations of the first returns.

On 1 August between 10:15 and 12:50 Universal Time, with the Lick Observatory 120-inch (304-cm) telescope and a laser operating at 6943 angstroms, return signals from an optical retro-reflector array placed on the moon by the Apollo 11 astronauts were successfully detected. After the return signal was first detected it continued to appear with the expected time delay for the remainder of the night. The observed range is in excellent agreement with the predicted ephemeris. Transmitting between 7 and 8 joules per pulse, we found that each return signal averaged more than one photoelectron. This is in good agreement with calculations of the expected signal strength.