Does Clubfoot Treatment Need to Begin As Soon As Possible?

INTRODUCTION: Parents of an infant with an idiopathic clubfoot deformity are often urged by their primary care physician to seek treatment as soon as possible. This advice frequently appears in many general pediatric and pediatric orthopaedic textbooks and monographs on the subject. This recommendation has not changed since the wide acceptance of the minimally invasive Ponseti method to treat clubfoot. We determined the correlations among patient-related variables, early treatment variables, and the age at which the patient was first seen to begin treatment. METHODS: Infants with moderate to very severe idiopathic clubfoot deformity were invited to participate. Age at which the patient presented to begin treatment was correlated against early treatment-related variables, including number of casts required, cast slippage, cast-related skin problems, brace-related skin problems, early noncompliance with brace wearing, and relapse before 1 year. Patient-related variables were also correlated against age at first visit. RESULTS: Over 7 years, 176 infants met the inclusion criteria. There were no significant differences in the aspects of the early management as a function of age at first visit, with the exception of cast slippage (P=0.05). CONCLUSIONS: The age at first visit influenced the incidence of cast slippage, but otherwise did not affect the early treatment of clubfoot. CLINICAL RELEVANCE: The treatment of idiopathic clubfoot deformity should not be considered an orthopaedic emergency, and parents whose infants are born with this deformity should be counseled accordingly.

The Outcome of Surgical Treatment of Multidirectionally Unstable (Type IV) Pediatric Supracondylar Humerus Fractures.

BACKGROUND: The outcome of multidirectionally unstable (type IV) supracondylar humerus fractures (SCHF) has been rarely described. We aimed to describe several aspects related to the diagnosis, treatment, and outcome of this complex injury. METHODS: We analyzed the clinical and radiographic data on 130 completely displaced SCHF in children, which was collected prospectively over a 6-year period (2007 to 2013), as part of an IRB-approved study. A minimum follow-up of 6 weeks was required. We compared the outcome of type IV SCHF (n=12, group 1) with that of type III SCHF (n=118, group 2) by assessing the need for open reduction, length of operative time, recovery of range of motion (as compared with the normal, contralateral side), and rate of complications. RESULTS: An open reduction was required in 17% and 2% of fractures in groups 1 and 2, respectively (P=0.04). A medial pin was added to supplement the fixation in 42% and 17% of fractures in groups 1 and 2, respectively (P=0.05). An acceptable reduction was obtained in all fractures. Surgery was longer for fractures in group 1, by a mean of 22 minutes (P=0.0001). No patient in either group required a reoperation. There was no significant difference between groups with respect to the latest range of motion of the treated side, as compared with the normal contralateral side (98% vs. 97%, respectively, P=0.4). Satisfactory outcomes were found in 92% and 98% of patients in groups 1 and 2, respectively (P=0.6). CONCLUSIONS: The results of this study suggest that a satisfactory outcome can be expected when treating type IV SCHF in a child. Although these fractures are associated with increased levels of technical difficulty, given the increased need for open reduction, utilization of medial pins, and longer surgical times, adequate reductions and satisfactory mid-term to long-term outcomes can be achieved. LEVEL OF EVIDENCE: Level II.

Closed Reduction and Percutaneous Pinning of Displaced Pediatric Lateral Condyle Fractures of the Humerus: A Cohort Study.

BACKGROUND: In treating pediatric lateral condyle fractures (LCFs) of the humerus, closed reduction and percutaneous pinning (CRPP) is an attractive alternative to open reduction and internal fixation (ORIF) because of the potential decrease in tissue injury, shorter surgical times, and faster functional recovery. However, there is limited information available regarding its outcome. METHODS: The data on 191 pediatric LCFs [163 fractures (85%) treated with ORIF (group 1) and 28 fractures (15%) treated with CRPP (group 2)], who were followed for over 12 weeks, was included in the present analysis. We compared several aspects related to the outcome of CRPP (as compared with ORIF), including issues related to surgical time, recovery of range of motion, lateral spur formation, complications, and overall outcome. RESULTS: The surgical time was significantly shorter for patients in group 2 (mean: 25.4 min; range: 18 to 50 min), as compared with group 1 (mean: 52.6 min; range: 24 to 121 min). A nearly anatomic reduction (<2 mm of residual displacement) was obtained in all fractures. No intraoperative or immediate postoperative complications were observed. The recovery of range of motion was similar in both groups: during the latest follow-up appointment, elbows in group 1 and 2 had achieved a mean relative arc of motion of 99.2% and 99.7%, respectively (P=0.3). Lateral spur formation was seen in 75% of fractures in group 1 and in 68% of fractures in group 2 (P=0.2). The overall rate of complications was 6.3% and 3.6% for fractures is groups 1 and 2, respectively (P=0.5). A satisfactory outcome was observed in 88.3% of fractures in group 1 and in 89.3% of fractures in group 2 (P=0.6) (Table 1). CONCLUSIONS: CRPP is a viable alternative for the treatment of pediatric LCFs with limited initial displacement (between 2 and 4 mm). In addition to the obvious cosmetic advantage of avoiding an unsightly scar, it is associated with decreased surgical times and does not significantly increase the incidence of complications.

Elbow dislocation with an associated lateral condyle fracture of the humerus: a rare occurrence in the pediatric population.

BACKGROUND: In the pediatric population, reports of a concomitant lateral condyle fracture (LCF) of the humerus and an elbow dislocation are rare. METHODS: From 2007 to 2013, we identified a group of 12 children who presented to our institution with a concomitant LCF and an elbow dislocation. This subset of fractures (group 1), all of which were managed surgically, is the subject of the present report. Their outcome was compared with that of all LCFs that were treated surgically at our institution during the study period (group 2, n=179). The length of surgery, recovery of range of motion (ROM), lateral spur formation, and the presence or absence of neurological or vascular complications, pin-tract infection, loss of fixation, and avascular necrosis or nonunion of the lateral condyle were used to describe the outcome of the fracture. RESULTS: A concomitant elbow dislocation and LCF of the humerus was observed in 12 patients with a mean age of 5.5 years (range, 2 to 8), and a mean follow-up of 51 weeks. A posteromedial dislocation of the elbow was observed in most patients. The recovery of ROM appeared to be slower for patients with an associated elbow dislocation, but a full recovery of ROM was obtained in the long term. Lateral spur formation was seen in all fractures in group 1 and only in 72% of fractures in group 2 (P=0.02). A satisfactory outcome was observed in 92% of fractures in group 1 and in 88% of fractures in group 2 (P=0.58). CONCLUSIONS: Concomitant LCF of the humerus and an elbow dislocation are rare. Satisfactory outcomes can be expected when prompt reduction of the elbow dislocation and timely anatomic reduction and fixation of the fracture is obtained. A delayed recovery of elbow motion is common among this population, but a full recovery of ROM can be expected in the long term. LEVEL OF EVIDENCE: Level II-retrospective.