Early morbidity associated with fasciotomies for acute compartment syndrome in children.

PURPOSE: Acute compartment syndrome (ACS) requires urgent fasciotomy to decompress the relevant muscle compartment/s prior to onset of irreversible myonecrosis and nerve injury. A fasciotomy is not a benign procedure. This study aims to describe and quantify early morbidity directly associated with fasciotomies for ACS in children. METHODS: Clinical charts of 104 children who underwent 112 fasciotomies over a 13-year period at a tertiary children's hospital were reviewed. The following were analyzed: ACS aetiology, fasciotomy site, number of subsequent procedures, method of wound closure, short-term complications and length of hospital stay. RESULTS: Short-term complications included wound infections (6.7%) and the need for blood transfusion (7.7%). Median number of additional operations for wound closure was two (0 to 10) and median inpatient stay was 12 days (3 to 63; SD 11.7). After three unsuccessful attempts at primary closure, likelihood of needing skin grafting for coverage exceeded 80%. Analyses showed that fasciotomy-wound infections were associated with higher risk for four or more closure procedures. Number of procedures required for wound closure correlated with longer inpatient stay as did ACS associated with non-orthopaedic causes. CONCLUSION: Fasciotomy is associated with significant early morbidity, the need for multiple closure operations, and prolonged hospital stay. The decision for fasciotomy needs careful consideration to avoid unnecessary fasciotomies, without increasing the risk of permanent injury from missed or delayed diagnosis. Skin grafting should be considered after three unsuccessful closure attempts. Less invasive tests or continuous monitoring (for high-risk patients) for compartment syndrome may help reduce unnecessary fasciotomies. LEVEL OF EVIDENCE: Level IV, Case series.

Supracondylar humeral fractures in children: beware the medial spike.

Supracondylar humeral fractures are common in children, but there are no classification systems or radiological parameters that predict the likelihood of having to perform an open reduction. In a retrospective case-control study we evaluated the use of the medial spike angle and fracture tip-skin distance to predict the mode of reduction (closed or open) and the operating time in fractures with posterolateral displacement. A total of 21 patients (4.35%) with a small medial spike angle (< 45°) were identified from a total of 494 patients, and 42 patients with a medial spike angle of > 45° were randomly selected as controls. The medial spike group had significantly smaller fracture tip-skin distances (p < 0.001), longer operating times (p = 0.004) and more complications (p = 0.033) than the control group. There was no significant difference in the mode of reduction and a composite outcome measure. After adjustments for age and gender, only fracture tip-skin distance remained significantly associated with the operating time (ß = -0.724, p = 0.042) and composite outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold for open reduction when treating patients with a small medial spike angle and a small fracture tip-skin distance.

Heelys injuries in children.

INTRODUCTION: Heelys, a type of shoes with stealth wheels, are extremely popular among children in Singapore. The widespread availability of cheap imitations has led to a proliferation of young users. Coupled with a total lack of safety equipment and instructions, these shoes can lead to significant injuries. The purpose of this study was to examine the incidence and type of injuries sustained by children using Heelys. METHODS: During a seven-month period from February to August 2004, all children treated at the Paediatric Orthopaedic Department of the KK Women's and Children's Hospital, were asked if the injury was sustained while "heeling". All the patients were reviewed by the authors. A total of 37 patients with significant injuries sustained while "heeling" were identified. Their radiographs and clinical charts were reviewed. The patients and/or their parents were also interviewed to obtain additional information. RESULTS: Upper limb injuries were by far the most common. Distal radius fractures and elbow injuries predominated. None of the children used safety gear. CONCLUSION: "Heeling" can lead to serious injuries despite the relatively low velocity involved. Children and their parents need to be educated on the use of safety gear.

Limited magnetic resonance imaging (MRI) and the occult hip fracture.

INTRODUCTION: Diagnosis of hip fracture is normally readily made from clinical evaluation and plain radiographs. Occasionally, clinical suspicion of fracture is not confirmed on plain X-rays. MATERIALS AND METHOD: Between January 2001 and March 2002, 422 patients were admitted to our department for post-traumatic hip pain. The diagnosis of hip fracture was unequivocally made in 365 patients (86%). Fifty-seven (14%) patients had a negative or equivocal radiograph. RESULTS: Limited magnetic resonance imaging (MRI) of the hip in this group of 57 patients confirmed that 8 (14%) sustained a femoral neck fracture, while 5 (9%) had an intertrochanteric fracture. In 19 patients (33%), some other pathology was found, mainly stable fractures of the femoral trochanters and pubic rami. Overall, 32 scans (56%) were positive and 25 (44%) were negative. Limited MRI detected patients with undisplaced hip fractures and identified them as candidates for surgery. CONCLUSION: The use of MRI in this specific and 'limited' way provides orthopaedic surgeons with a rapid, accurate and cost-effective diagnostic tool in this clinical scenario. Definitive diagnosis allows the correct management plan to be implemented early. We recommend that patients, who have significant hip pain following injury but indeterminate plain radiographs, undergo a limited MRI scan as a matter of routine.