Management of paediatric humeral shaft fractures and associated nerve palsy.

PURPOSE: The aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period. METHODS: Retrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up. RESULTS: Of 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery. CONCLUSION: Over a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention. LEVEL OF EVIDENCE: IV.

Stereoradiography imaging motion artifact: does it affect radiographic measures after spinal instrumentation?

PURPOSE: Stereoradiography imaging (SRI) is an accurate and reliable low-dose radiographic method. However, patients must remain motionless during image acquisition. Motion artifacts are frequently noted. The aims of the study were to determine the incidence of the SRI motion artifact and assess if motion during SRI acquisition affects radiographic measurements. METHODS: In this retrospective study, 198 patients with spinal instrumentation had biplanar SRI radiographs performed, of whom 39 had concomitant conventional radiographs. Eight coronal and sagittal spinal parameters were independently measured on SRI and conventional radiographs for the 39 patients by 2 observers. Inclusion criteria were: presence of spinal instrumentation of more than six levels and an SRI motion artifact identified on the coronal and/or the sagittal views on either the spinal rods or on the limbs. Means were compared between both types of radiographs using the Student's t test; intraclass correlation coefficients (ICCs) were used for intraobserver reproducibility and interrater reliability. RESULTS: A motion artifact was identified in 19.7 % (n = 39, mean age 19.5 ± 1.7 years) of the cases. There were no differences in any of the coronal or sagittal plane measurements between SRI and X-rays. Intraobserver reliability and interrater reproducibility was high (range 0.81-0.98). CONCLUSIONS: Motion artifact during full-spine stereoradiography imaging acquisition is frequent, but does not affect spinal measurements. SRI with a motion artifact can be used to produce reliable measurements of the sagittal and coronal parameters. Some SRI images with a motion artifact may suggest loss of fixation or bending of the rods. However, after becoming familiar with the appearance of the motion artifact, repeat radiographs are rarely indicated. IRB NUMBER: 14-004872. LEVEL OF EVIDENCE: Level IV.

Revision interposition arthroplasty of the elbow.

Between 1996 and 2008, nine patients with severe post-traumatic arthritis underwent revision of a failed interposition arthroplasty of the elbow with a further interposition procedure using an allograft of tendo Achillis at a mean of 5.6 years (0.7 to 13.1) after the initial procedure. There were eight men and one woman with a mean age of 47 years (36 to 56). The mean follow-up was 4.7 years (2 to 8). The mean Mayo Elbow Performance score improved from 49 (15 to 65) pre-operatively to 73 (55 to 95) (p = 0.04). The mean Disability of the Arm, Shoulder and Hand score was 26 (7 to 42). One patient was unavailable for clinical follow-up and one underwent total elbow replacement three months post-operatively. Of the remaining patients, one had an excellent, two had good, three fair and one a poor result. Subjectively, five of the nine patients were satisfied. Four continued manual labour. Revision interposition arthroplasty is an option for young, active patients with severe post-traumatic arthritis who require both mobility and durability of the elbow.