Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them.

Flexible intramedullary nailing has become a popular method of fixation of pediatric femoral fractures. The authors analyzed their first 5-year experience with titanium elastic stable intra-medullary nailing, specifically to report the complications associated with this technique and to provide recommendations to avoid these complications. Seventy-eight children with 79 femoral fractures were treated by this method. Complications included pain/irritation at the insertion site (41), radiographic malunion (8), refracture (2), transient neurologic deficit (2), and superficial wound infection (2). Ten patients required reoperation prior to union. Malunion and/or loss of reduction requiring reoperation was strongly associated with the use of nails of mismatched diameters (odds ratio = 19.4) and comminution of more than 25% (odd ratio = 5.5). Pain at the insertion site was significantly associated with bent or prominent nail ends. Most complications are minor, and many are preventable. Surgeons should advance nail ends to lie against the supracondylar flare of the femur to avoid symptoms at the insertion site and should avoid implanting nails of two different diameters. Comminuted fractures should be monitored carefully and might benefit from additional immobilization.

Mangled extremity severity score in children.

Treatment of the severely traumatized or mangled lower extremity poses significant challenges. The Mangled Extremity Severity Score (MESS) is a scale that uses objective criteria to assist with acute management decisions. Most research on the MESS has been in adults or combined series with few children. The study was performed to investigate the MESS in children exclusively. The MESS was applied retrospectively to 36 patients with grades IIIB and IIIC open lower extremity fractures collected from two level 1 pediatric trauma centers. Patients were divided into limb salvage and primary amputation groups based on the decision of the treating surgeon. In the salvage group there were 18 grade IIIB fractures and 10 grade IIIC fractures. The MESS prediction was accurate in 93% of the injured limbs. In the amputation group eight limbs met the inclusion criteria; the MESS agreed with the treating surgeon in 63% of cases. These findings suggest the MESS should be considered when managing a child with severe lower extremity trauma.

Sir John Golding

The funeral of John Golding, organised by the Jamaican government and attended by the prime minister and leader of the opposition, and the numerous tributes from colleagues testify to John Golding's impact on his adopted country. He was honoured with the Order of Jamaica and the road to the hospital was name for him. He first went there in 1953 as senior lecturer in orthopaedics; six months later Jamaica was struck with its first major outbreak of poliomyelitis, which affected 1500 children. To cope with this he helped set up a rehabilitation unit in a disused drama theatre. In time this became the Mona Rehabilitation Centre serving the whole English speaking Caribbean. Golding also established the Hope Valley School, ensuring that handicapped people had the stimulus of working along side those who were not; a farm; and Monex, a company selling jewellery and woodwork made by the patients. The last also made all the island's flags, repaired the hospital's linen cleaned specimen tubes for reuse in the hospital laboratories, and serviced headsets for Air Jamaica. Other initiatives included fundraising through Christmas cards and a fun fair, a woodshop to produce artificial joints using recycled aluminium, a school of physical therapy, the Cheshire Home, and hospice care. Aged 71, Golding initiated the National Road Safety Council of Jamaica, which had introduced breathalysers, and at the time of his death he was campaigning for car seat belts. All this was achieved in addition to the usual heavy workload of a professor of orthopaedic sugery, and outside commitments such as being secretary general of World Orthopaedic Concern and chairman of the Medical Research Council of the Caribbean. He leaves a wife, Pat (who enabled him to achieve so much), a son and a daughter, and four grandchildren. (AU)

Current practice in orthopaedics: compound fractures

Damage to soft tissues takes priority over bony damage in the treatment of compound fractures. Bony displacement can always be corrected later but the soft tissues must be cleansed and closed early - preferably by skin grafting. The duration of invalidism and the quantity of medical and nursing attention required is inversely proportional to the speed and thoroughness of initial treatment (AU)

Paralytic dislocation of the hip in poliomyelitis

Curiously, the hip dislocates spontaneously when the extensors and adductors alone are paralysed but not when the hip is totally paralysed. Mechanical and electromyographic investigations provide an answer to this enigma. When weight is taken on the totally paralysed hip during walking, only body weight is imposed on the hip. When weight is taken on a hip with active adductor, the contraction of the adductor, which spans the hip joint and is active at this phase of gait on E.M.G., increases the load by 200 percent. At this time the hip is adducted (due to the dipping gait), and the hip is in its most unstable position. The line of the combined forces of gravity and adductor contraction is such that they tend to displace the head of the femur from the acetabulum. Radiology reveals a further defect in the roof of the acetabulum and a notch in the head of the femur. These lock in certain position of the hip levering the head further out of the acetabulum. The anatomical changes and treatment are entirely different from congenital dislocation which is a persistent anterior dislocation. Paralytic dislocation is a recurrent posterior dislocation, and has features in common with recurrent dislocation of the shoulder. The implications for treatment are (1) that fixed adduction should be overcome, (2) muscle power should be rebalanced by tendon transfer, and (3) smallbone defects should be repaired. Disorganised joints should be left alone and regarded as an indication for a leg equalisation procedure (AU)