Outcomes of Pediatric Fractures Managed With Closed Reduction by Orthopaedic Residents in the Emergency Department.

BACKGROUND: Closed reduction of pediatric fractures is commonly performed by orthopaedic residents using conscious sedation in the emergency department (ED). The purpose of this study was to determine the rate of satisfactory reductions as performed by residents, and to determine the outcomes of these procedures. METHODS: A retrospective review was performed of all fractures that underwent closed reduction under conscious sedation in the ED of a level 1 pediatric trauma center between January 1, 2010 and November 30, 2014. Initial and subsequent radiographs were reviewed and a determination was made as to whether the initial reduction was satisfactory, based on predetermined criteria for angulation and displacement. If a second reduction attempt in the operating room was necessary, this was noted. Chart notes were reviewed until a documented endpoint was reached, such as uneventful healing, malunion, nonunion, or growth arrest. RESULTS: A total of 838 subjects were identified. The upper extremity was involved in 85% of the fractures. Of the initial 838 fracture reductions performed, 39 (4.7%) were unsatisfactory. Residents on their first pediatric orthopaedic rotation had a higher unsatisfactory reduction rate compared with more experienced residents (7.0% vs. 3.4%, P=0.01). A second reduction was performed for 94 of 749 (12.6%) fractures. Of these, 35 (37.2%) required an open procedure to accomplish a satisfactory reduction. Fractures with initially satisfactory reductions were significantly less likely to require a second reduction attempt than those with initially unsatisfactory reductions (9.2% vs. 80.0%, P<0.01). The likelihood of a satisfactory reduction was significantly higher in the upper extremity than in the lower extremity. Overall, the vast majority (99.2%) of fractures had a satisfactory final outcome. CONCLUSIONS: Most attempts at closed reduction of pediatric fractures in the ED by orthopaedic residents are successful, and the likelihood of a satisfactory reduction was associated with increased levels of resident experience. Fractures with an initially successful reduction were far less likely to require remanipulation. LEVEL OF EVIDENCE: Level IV-this is a therapeutic case series.

Vertebral artery injuries in cervical spine surgery.

BACKGROUND CONTEXT: Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. PURPOSE: We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. STUDY DESIGN: The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). PATIENT SAMPLE: All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. OUTCOME MEASURES: For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. METHODS: An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. RESULTS: One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). CONCLUSIONS: The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases.

Biomechanical evaluation of locking plate fixation with hybrid screw constructs in analogue humeri.

Locking plates are well suited to complex fracture patterns and weak bone. In the study reported here, we compared the structural stability of 3 different locking compression plate (LCP) constructs using composite analogue humeri. Eighteen analogue composite humeri were used as bone models. A 6.5-mm osteotomy gap was stabalized with a 9-hole 3.5-mm narrow LCP using four 3.5-mm self-tapping screws on each side of the fracture with the middle hole empty. Three construct configurations were studied: B (all screws bicortical), BU (bicortical screw on each side of fracture gap and remaining screws unicortal), and U (all screws unicortal). Each bone model was fixed in a customized jig and subjected to mediolateral and anteroposterior 4-point bending and external rotational torque to assess rigidity, stiffness, and failure. There was significant (P<.05) differences in torsional stiffness but no significant differences in terms of flexural rigidity between each of the constructs. The results also indicated that construct BU provided as much stability as the other constructs. Therefore, consideration should be given to type of fixation construct, especially when torsional stability is required. Replacing a single set of unicortal locking screws with bicortical locking screws closer to the fracture site improved construct stability compared with any unicortal screw construct. A hybrid fixation construct that provides bicortical screws at any location may provide equivalent construct stability in this model. Hybrid fixation constructs may provide adequate fracture stabilization for a fracture pattern that would typically be considered unstable.

Structural properties of a novel design of composite analogue humeri models.

BACKGROUND: Mechanical analogue composite bone models have been used as cadaveric bone substitutes in a wide variety of biomechanical tests. The objective of this study was to compare the structural properties of two types (Third- and Fourth-Generation) of commercially available composite analogue humeri. METHODS: Eighteen of each generation composite analogue humeri were evaluated for flexural rigidity, torsional rigidity, and failure strength. Three tests were performed: medial-lateral four-point bending, anterior-posterior four-point bending, and external rotational torque. RESULTS: The Fourth-Generation analogue humeri performed more closely to the biological average with respect to failure strength, flexural rigidity, and torsional stiffness when compared to the Third-Generation humeri. Both the Third- and Fourth-Generation analogues were within the range of published human bone values. There was a statistically significant difference in strength in all modes of testing between the Fourth-Generation humeri and the Third-Generation humeri. CONCLUSION: These composite analogue humeri are ideal for standardization in biomechanical analyses. The advantage of these humeri is that their variability is significantly lower than that of cadaveric specimens for all loading regimens. The widely varying results observed when comparing composite analogue humeri to cadaveric humeri might be derived from the use of different ranges of applied load, varied test methodologies, and diverse methods of computing the stiffness. Mechanical validation of whole Fourth-Generation humeri bone models would be an appropriate follow-up to this study with a direct comparison to cadaveric humeri. CLINICAL RELEVANCE: This study validated and advanced our overall understanding of the capacity of composite analogue humeri to model the structural properties of human bone.