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.

Use of a custom retrograde intramedullary rod for the management of distal femoral nonunion: a report of two cases.

Nonunion of the distal femur is a rare injury that is difficult to manage. A variety of surgical implants and techniques are available. We present an alternative mode of treatment for supracondylar femoral nonunion using a custom retrograde titanium femoral nail (Biomet; Warsaw, IN) to successfully achieve union in two cases. We believe the added length, custom modifications, and enhanced stability allowed better fixation in an osteopenic distal femur.

Open reduction and internal fixation of a glenoid fossa fracture in a child: a case report and review of the literature.

Scapular fractures in children are rare injuries. The indications for the surgical treatment of glenoid fossa fractures in children are not well defined. We report on an eight-year-old child with a displaced glenoid fossa fracture requiring open reduction and internal fixation. A review of the literature and indications for the operative management of glenoid fossa fractures in children are discussed.

Bilateral posterior fracture-dislocation of the shoulders: management by bilateral shoulder hemiarthroplasties.

Bilateral posterior fracture-dislocation of the shoulders is rare, with only 26 reported cases in the literature. We present the case of a patient who sustained bilateral posterior fracture-dislocations after a first time seizure. Due to significant articular surface involvement, bilateral hemiarthroplasties were performed. The literature on this injury and current treatment options is also reviewed.

The management of the soft tissues in pilon fractures.

Fourteen patients with 15 pilon fractures were reviewed retrospectively to analyze cases treated by open reduction and internal fixation through both anteromedial and lateral incisions. The protocol for this procedure involved objective soft-tissue evaluation, anteromedial wound closure, judicious use of primary skin grafting, and delayed primary or secondary closure for the lateral wound. Eleven fractures were treated according to the established principles of the Association for the Study on Internal Fixation (AO/ASIF). The type and incidence of wound complications were recorded. Most injuries reviewed were of the high-energy or Type III fracture as defined by Reudi and Allgower. There was only one patient with a wound complication. This technique minimized the potential for wound complication and disastrous disability.

Irreducible talar dislocation with entrapment by the tibialis posterior and the flexor digitorum longus tendons. A case report.

Complete open-talar dislocation irreducible by virtue of entrapment by the tibialis posterior and flexor digitorum longus tendons occurred in a 41-year-old woman. Two-year follow-up examination revealed no evidence of avascular necrosis. A cursory review of the literature suggests that recovery of a complete range of motion is unusual.

Tibialis posterior muscle: the fifth compartment?

The posterior aspect of 51 embalmed cadaver legs in 50 cadavers was dissected to establish the prevalence of a separate compartment for the tibialis posterior muscle (TP). All dissections revealed the presence of a superficial and a deep posterior compartment. No distinct fascial septum separated the TP from the flexor digitorum longus (FDL) and flexor hallucis longus (FHL). We conclude that the TP does not commonly rest within its own osseofascial compartment and thus does not require isolated decompression for acute compartment syndrome of the leg. An incidental observation, frequently overlooked in the anatomy literature, was a supplemental tendon of origin of the FDL. In addition to the classically described tibial origin, several cadavers exhibited a proximal fibular tendon of origin for the FDL. One cadaver demonstrated the FDL to have an extensive fibular origin that completely covered the TP, forming a myotendinous fifth compartment. We feel that the variable fibular origin can explain the chronic exertional compartment syndrome of the TP described previously by Davey et al. and serves as a basis for a minor alteration in our fasciotomy technique.

Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.

Eight patients with unstable fractures involving the articular surface and metaphyseal-diaphyseal bone of the proximal or distal tibia associated with severe soft-tissue injury or compounding wound were treated with irrigation, debridement, tetanus inoculation, antibiotic prophylaxis, and combined internal fixation with one-half frame external skeletal fixation for neutralization. All patients were followed to complete healing and functional restoration of the extremity. All fractures healed, but one superficial and one deep infection occurred. All patients achieved at least 110 degrees of knee motion. This method should be considered in unstable metaphyseal and articular tibia fractures not adequately stabilized with a lateral plate in which use of an additional medial plate is required for stability, but contraindicated because of the status of the soft tissues or extensive comminution of the bone.

Management of resistant pseudarthrosis of long bones.

A retrospective review was undertaken of 15 patients with long-bone pseudarthrosis with long-standing nonunion. These patients were referred to a tertiary care center after their fractures failed to unite after numerous surgical attempts as well as a course of electrical stimulation. Fourteen patients had nonunion of the tibia, and one had nonunion of a humerus fracture. Twelve were originally Gustillo Grade II or III fractures, and four sustained multiple injuries. The average duration of nonunion before presentation to the clinic was 22.5 months. Five patients presented as infected nonunions. Each nonunion was analyzed with specific reference to injury mechanism, skin and bone conditions, presence of infection, primary treatment protocol, and selection criteria for treatment with electrical stimulation. Review of the data revealed that the most common factor associated with failure of electrical stimulation treatment was inappropriate patient selection, according to criteria previously published for the use of these techniques. Treatment modalities consisted of intramedullary fixation in three, open reduction and internal fixation using Arbeitsgemeinschaft fur Osteosynthesefragen (AO) technique in nine, and external fixation in three. All patients were bone grafted. The mean follow-up duration was 1.5 years. Nonunions were healed in fourteen patients. Twelve were fully weight bearing at six months, and one at 12 months. Success was defined as restoration of a functional extremity, giving a success rate of 87%. A thorough reevaluation of the original treatment regimen and a return to basic principles of operative fracture management and bone grafting can yield excellent results, even in patients with recalcitrant nonunion.

Pin tract infections: a canine model.

The purpose of this study was to examine three issues: the relationship between the length of time of skeletal pin insertion and bacterial infection, the connection between skin organisms and the intramedullary infecting agent, and the length of time necessary for the medullary canal to sterilize itself after pin removal. Skeletal pins were inserted in a group of dogs, and a direct correlation was found between the duration of time that the pins remained in the bone and positive intramedullary cultures. The infecting agent in 88% of the medullary cultures was also cultured from the skin. In a second group of dogs, the pins remained in place for 1, 2, 3, or 4 weeks, respectively. The pins were removed, and the pin tracts were permitted to heal for varying periods of time. The medullary canals were then cultured. No medullary canal was infected when the pin tracts were allowed to heal for greater than or equal to 3 weeks. Therefore, if pin tracts are allowed to heal for at least 3 weeks prior to performance of osteosynthesis, the chances of deep infection are probably lessened.