Upper Extremity Friction Burns in the Pediatric Patient: A 10-year Review.

BACKGROUND: Upper extremity friction burn due to powered home equipment is a growing problem in the pediatric population. The purpose of this study was to review the etiology, presentation, characteristics, and treatment of this particular type of pediatric mechanism of injury. METHODS: A retrospective chart review using International Classification of Diseases, version 9, codes for patients treated at a large tertiary care, free-standing children's hospital was performed to identify all patients presenting with an upper extremity friction burn from 2003 to 2012. RESULTS: Sixty-nine patients sustained upper extremity friction burns. The average age at the time of injury was 3.3 years (range, 0.7-10.6) with presentation to our center occurring 16.6 days (range, 0-365 days) following injury. Mean follow-up was 23.3 months (range, 2-104). Mechanism of injury included treadmills (n = 63) and vacuum cleaners (n = 6). Twenty-eight operations were performed on 21 patients (30%). All patients requiring a surgical intervention sustained injury via treadmill mechanism (P = 0.0001). Unlike treadmill burns, vacuum cleaner injuries affected the dorsal hand or a single digit (P = 0.00004). Scar hyperpigmentation was more prevalent in these patients compared with the treadmill group (P = 0.003). All vacuum-induced burn patients had full range of motion and function with conservative treatment alone, whereas only 55.6% of treadmill burn patients had full recovery of range of motion and 50.8% recovery of full hand function. CONCLUSIONS: Friction burns from vacuum cleaners are less prevalent, have different injury patterns, and can be treated conservatively with excellent functional outcomes. Treadmill friction burns result in more significant injury and risk for dysfunction, requiring surgical intervention.

Upper Eyelid Coloboma Repair Using Accessory Preauricular Cartilage in a Patient With Goldenhar Syndrome: Technique Revisited.

We present an unusual case of upper eyelid coloboma repair in a patient with Goldenhar syndrome. We describe the use of a modified Cutler-Beard flap with concurrent inlay graft using cartilage from a preauricular appendage. This technique provides the benefits of autologous tissue, while minimizing donor site morbidity and reducing the risk of upper eyelid retraction.

Columellar Reconstruction After Nasal Continuous Positive Airway Pressure Associated Necrosis.

Though a life-saving modality in neonatal intensive care units, nasal continuous positive airway pressure (nCPAP) carries a small risk of irreversible ischemia and necrosis of the columella due to the configuration of the pressure delivery system. Iatrogenic injuries to the columella after nCPAP use result in a spectrum of disfigurement and functional airway obstruction. The authors performed a retrospective review of patients evaluated for nCPAP-related columellar deformities by the Division of Plastic and Reconstructive Surgery at the authors' institution over a 10-year period to assess reconstructive outcomes. Of 7 patients evaluated, 3 underwent reconstruction using a combination of cartilaginous framework reshaping and local tissue flaps. After a mean follow-up period of 78 months, patients had satisfactory aesthetic and functional results. Based on the authors' observations, columellar necrosis secondary to nCPAP can be divided into 3 categories: Type A demonstrates mild notching of the columella; Type B has an absent columella without notable nasal tip depression; Type C has an absent columella with nasal tip depression, with or without external nasal valve obstruction. Reconstructive needs should be individually tailored based on the degree of nasal tip depression, cartilaginous support, and soft tissue availability.

An Unconventional Presentation of Branchio-Oculo-Facial Syndrome.

Branchio-oculo-facial syndrome (BOFS) is a rare disorder characterized by branchial or pharyngeal arch malformations, ocular findings, and craniofacial anomalies. Activating mutations in the enhancer-binding protein 2 alpha, TFAP2A, gene is responsible for the autosomal-dominant inheritance of BOFS. While documented patients of BOFS report wide variability in phenotype expressivity, patients typically demonstrate cervical or infra-auricular anomalies, diverse ocular malformations including microphthalmia and coloboma, and highly characteristic pseudo-cleft or palate defects. The authors present the case of an infant with an unconventional presentation of BOFS to highlight key distinguishing features of this disorder, and to emphasize the importance of a multidisciplinary approach in the diagnosis and management of these patients.

Salmonella osteomyelitis of the hand in an infant with sickle cell disease.

Salmonella osteomyelitis involving the hand is a rare, but potentially morbid, complication of sickle cell disease in children. This entity can be difficult to distinguish from the more frequent presentation of dactylitis, but accurate diagnosis is critical to direct proper treatment. We report on a 15-month-old patient with sickle cell disease who ultimately developed osteomyelitis of 1 hand after an acute vasoocclusive episode caused 4 extremity dactylitis. The case description illustrates the diagnostic and treatment challenges.

Clinical Factors Affecting Length of Stay After 100 Consecutive Cases of Primary Cleft Lip Repair.

OBJECTIVE: To analyze the hospital course of 100 consecutive infants after primary cleft lip repair (PCLR) and identify factors related to length of stay (LOS). DESIGN: Retrospective analysis of 100 consecutive infants who were routinely admitted after PCLR. SETTING: Tertiary care center. PATIENTS: One hundred consecutive infants undergoing PCLR. Demographic and perioperative data were collected and analyzed. MAIN OUTCOME MEASURE: LOS, planned before data collection. RESULTS: Male:female ratio was 65:35. Seventy-two infants had unilateral cleft lip; syndromic association was documented in 15 patients. Mean age and weight at PCLR were 5.6 ± 4.0 months and 6.7 ± 1.3 kg, respectively. Mean duration of surgery was 2.5 ± 0.9 hours, and mean duration of general anesthesia was 3.4 ± 0.9 hours. A total of 3.3 ± 1.5 mL of intraoperative local anesthetic was used per patient. Intravenous fluids were necessary after transfer from the post-anesthesia care unit to the general ward in 98% of patients. Almost half (44%) of all patients received intravenous morphine 23 hours or more after hospital admission. Mean LOS was 35.8 ± 13.9 hours. No association was identified between patient demographic factors and LOS. Multivariate linear regression models identified significant positive correlation between LOS and duration of general anesthesia (P = .002). Greater volume of postoperative oral intake (P = .000) and higher acetaminophen dosage on the floor (P = .000) correlated with decreased LOS. CONCLUSIONS: This study identifies perioperative factors associated with LOS. Our findings question the safety of routine outpatient or short-stay observation after PCLR.

Craniectomy gap patency and neosuture formation following endoscopic suturectomy for unilateral coronal craniosynostosis.

BACKGROUND: The combination of endoscope-assisted suturectomy and postoperative helmet therapy has been advocated to treat unilateral coronal synostosis. However, surgical outcomes can vary. One possible explanation for this inconsistency is early closure of the craniectomy gap. The authors examined short-term postoperative patency of the craniectomy gap and its relationship to phenotypic improvement. METHODS: A retrospective review was performed that included patients who (1) underwent endoscope-assisted suturectomy and postoperative helmet therapy for isolated unilateral coronal synostosis and (2) had preoperative and postoperative (>7 months) computed tomographic imaging. High-resolution computed tomographic images were analyzed for craniectomy gap patency. RESULTS: Seventeen patients met the inclusion criteria. Mean age at operation was 2.5 months (range, 1.1 to 4.7 months). Mean duration of follow-up was 32.9 months (range, 10.6 to 64.9 months) and age at latest postsurgical computed tomography was 16.8 months (range, 7.5 to 40.9 months). Fifteen patients demonstrated "neosuture" formation and coronal patency on postoperative computed tomography. Three patients (17.6 percent) had complete formation of a normal-appearing coronal suture, whereas 12 patients (70.6 percent) had areas composed of both reformed suture and persistent craniectomy gap. These 15 patients demonstrated satisfactory phenotypic improvement and did not require subsequent procedures. The remaining two patients (11.8 percent) exhibited focal areas of refusion interspersed with areas of neosuture formation and persistent craniectomy gap. Both had poor phenotypic improvement; one underwent fronto-orbital advancement. CONCLUSION: Persistence of a craniectomy gap and neosuture formation are common early findings after endoscope-assisted suturectomy and postoperative helmet therapy and appear to correlate with better phenotypic improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Endocortical plating of the bandeau during fronto-orbital advancement provides safe and effective osseous stabilization.

BACKGROUND: Ectocortical resorbable plate fixation has become a standard method of fixation during fronto-orbital advancement (FOA) in young children. Plate hydrolysis occurs slowly and can cause visible prominences, sterile abscesses, and osseous depressions that can persist after complete resorption. Although endocortical placement avoids contour issues, the safety and effectiveness of this technique are undocumented. METHODS: A review of our prospectively collected craniofacial database was performed. All patients undergoing FOA by a single craniofacial team at a single institution from 1997 to 2011 were examined. Inclusion criteria were as follows: (1) unicoronal, bicoronal, or metopic synostosis; (2) resorbable endocortical fixation of the bandeau; and (3) follow-up for 1 year or longer. Evaluation included patient demographic data, postoperative clinical course, and computed tomography imaging when available. RESULTS: Seventy-three patients met the inclusion criteria. Fusion involved the unicoronal (n = 26), bicoronal (n = 19), and metopic (n = 28) sutures. Mean age at operation was 8.3 months (range, 2.7-35.5 mo), and follow-up was 4.5 years (range, 1.0-9.9 y). No endocortical or ectocortical sterile abscesses were documented in our series. Postoperative complications included hematoma (n = 2), infection (n = 2), wound breakdown (n = 3), cerebral contusion (n = 2), and cerebrospinal fluid leak (n = 1); none of these issues were related to endocortical absorbable fixation. Fifty-eight patients (80%) were categorized as Whitaker classification I/II; and 15 patients (20%), Whitaker classification III/IV. Postoperative computed tomography (mean follow-up, 4.6 y) was obtained in 34 patients (47%). All plates were completely resorbed, and there were no bone or soft tissue irregularities in the region where the plates were placed. CONCLUSIONS: Endocortical resorbable fixation is a safe and effective method of osseous stabilization during FOA for craniosynostosis in young children.

Incidental findings on preoperative computed tomography for nonsyndromic single suture craniosynostosis.

Although the diagnosis of nonsyndromic single suture craniosynostosis (NSSC) can usually be made by clinical examination, computed tomography (CT) is still commonly used in preoperative evaluation. This practice has been questioned in light of recent studies that document a small, but measurable, increased risk of malignancy from CT-associated radiation. The purpose of this study was to examine whether preoperative CT for patients with NSSC provided clinically important information beyond confirmation of craniosynostosis. We performed a retrospective analysis of all patients with NSSC undergoing cranial vault remodeling at our center from March 1999 to March 2011. Only patients with complete preoperative CT scans available for review were included. Staff pediatric neurosurgeons were blinded to patient diagnosis and official radiology report, analyzed the CT images, and documented the site of synostosis and any other findings. Of the 231 patients, 80 met the inclusion criteria. Sites of synostosis included sagittal (51 patients), coronal (17 patients), metopic (11 patients), and frontosphenoidal (1 patient). Clinical diagnosis correlated with radiographic site of fusion in all patients except the patient with frontosphenoidal synostosis. Incidental findings were documented in more than 50% of the patients including prominent extra-axial cerebrospinal fluid (n = 36, 45%), ventriculomegaly (n = 5, 6.25%), choroid fissure cyst (n = 2), cavum septum pellucidum (n = 2), Chiari malformation (n = 1), and prominent perivascular space (clinically nonsignificant finding, n = 1). Incidental findings required additional follow-up or management in 5 patients (6.25%). Our findings support the use of preoperative imaging in this population to identify intracranial anomalies that cannot be discerned by clinical examination. Whereas many findings were not clinically important, some required additional attention.

Isolated frontosphenoidal synostosis: a rare cause of synostotic frontal plagiocephaly.

OBJECT: Unilateral fusion of the frontoparietal suture is the most common cause of synostotic frontal plagiocephaly. Localized fusion of the frontosphenoidal suture is rare but can lead to a similar, but subtly distinct, phenotype. METHODS: A retrospective chart review of the authors' craniofacial database was performed. Patients with isolated frontosphenoidal synostosis on CT imaging were included. Demographic data, as well as the clinical and radiographic findings, were recorded. RESULTS: Three patients were identified. All patients were female and none had an identifiable syndrome. Head circumference was normal in each patient. The mean age at presentation was 4.8 months (range 2.0-9.8 months); 2 fusions were on the right side. Frontal flattening and recession of the supraorbital rim on the fused side were consistent physical findings. No patient had appreciable facial angulation or orbital dystopia, and 2 patients had anterior displacement of the ipsilateral ear. All 3 patients were initially misdiagnosed with unilateral coronal synostosis, and CT imaging at a mean age of 5.4 months (range 2.1-10.8 months) was required to secure the correct diagnosis. Computed tomography findings included patency of the frontoparietal suture, minor to no anterior cranial base angulation, and vertical flattening of the orbit without sphenoid wing elevation on the fused side. One patient underwent CT scanning at 2.1 months of age, which demonstrated a narrow, but patent, frontosphenoidal suture. The patient's condition was assumed to be a deformational process, and she underwent 6 months of unsuccessful helmet therapy. A repeat CT scan obtained at 10.7 months of age demonstrated the synostosis. All 3 patients underwent fronto-orbital correction at mean age of 12.1 months (range 7.8-16.1 months). The mean duration of postoperative follow-up was 11.7 months (range 1.9-23.9 months). CONCLUSIONS: Isolated frontosphenoidal synostosis should be considered in the differential diagnosis of atypical frontal plagiocephaly.

Combined metopic and unilateral coronal synostoses: a phenotypic conundrum.

BACKGROUND: Most types of craniosynostosis cause predictable changes in cranial shape. However, the phenotype of combined metopic and unilateral coronal synostoses is anomalous. The purpose of this observational study was to better clarify the clinical and radiographic features of this rare entity. METHODS: A retrospective review of a craniofacial database was performed. Patients with combined metopic and unilateral coronal synostoses were included in this study. Data collected included demographic information, physical and radiographic findings, genetic evaluation, treatment, and operative outcomes. RESULTS: Of 687 patients treated between 1989 and 2010, only 3 patients had combined metopic and unilateral coronal synostoses. All patients were diagnosed through computed tomography on the first day of life. Phenotypic features included the following: (1) narrowed forehead with a prominent midline ridge, (2) severe bilateral brow retrusion with an acute indentation on the side of the patient coronal suture, (3) facial and nasal angulation similar to isolated unilateral coronal synostosis, and (4) anterior displacement of the ear on the fused side. In addition, the cranial vertex was deviated toward the side of the open coronal suture. Two patients had a head circumference below the 25th percentile; 2 of the 3 had a TWIST gene mutation consistent with Saethre-Chotzen syndrome. One patient was managed through fronto-orbital advancement and required a revision. The other 2 patients had early endoscopic release, followed by postoperative helmet therapy; one improved but still required open cranial remodeling. The other has near-normal phenotype, and no further surgery is planned. CONCLUSIONS: Combined metopic and unilateral coronal synostoses present a rare and unusual phenotype. Although early intervention improves the deformity, revisional procedures are usually required.

Analysis of routine intensive care unit admission following fronto-orbital advancement for craniosynostosis.

BACKGROUND: Intensive care unit admission following fronto-orbital advancement for craniosynostosis is routine at most institutions. The authors determined the frequency of postoperative events requiring intensive care unit care that justify this practice. METHODS: Infants with craniosynostosis who underwent primary fronto-orbital advancement at a single institution from 1997 to 2011 were included. Patient demographics, operative factors, and hemodynamic outcomes were recorded. Adverse postoperative events/interventions were graded as none (group I); minor (group II), easily managed on a surgical floor; or major (group III), requiring intensive care unit care. RESULTS: One hundred seven infants were included. Average length of hospitalization was 3.7 ± 1.6 days, with 1.3 ± 1.0 days in the intensive care unit and 2.4 ± 1.0 days on the floor. Seventy-eight patients (72.9 percent) were categorized into group I, 24 (22.4 percent) into group II, and five (4.7 percent) into group III. Major events/interventions included prolonged intubation (n = 2), reintubation (n = 2), and continuous positive airway pressure support (n = 1). Preexisting end-organ dysfunction was significantly associated with group III patients, who also had significantly higher intraoperative blood loss requiring greater resuscitation. Mean daily charges were $7652.33 (10.9 percent of total charges) for intensive care unit care and $2470.62 (6.9 percent of total charges) for floor care. CONCLUSIONS: In this study, 4.7 percent of patients had event/interventions requiring intensive care unit care after fronto-orbital advancement. Predictors included preexisting end-organ dysfunction and higher intraoperative blood loss requiring greater resuscitation. Financial savings from selective postoperative intensive care unit admission may not outweigh the potential cost of an emergent event on the surgical floor.

Correction of deformational plagiocephaly in early infancy using the plagio cradle orthotic.

BACKGROUND: The purpose of this study was to assess early treatment of deformational plagiocephaly using the Plagio Cradle, a modifiable cranial orthotic. METHODS: Infants were included if they had treatment of deformational plagiocephaly with the Plagio Cradle beginning at 4 months or younger. Patients were prospectively stratified by the age treatment was initiated: group 1: under 10 weeks (n = 50); group 2: 10 to 20 weeks (n = 113). Pretreatment and posttreatment calvarial asymmetry was measured using direct anthropometry and reported as a transcranial difference (TCD). The end point for therapy was a TCD of 5 mm or less, falling within 2 SDs of published normative data. RESULTS: One hundred sixty-three infants were included. Initial TCD was significantly higher for group 1 as compared with group 2 (initial TCD: 11.0 vs 9.0 mm; P < 0.05). Duration of therapy was significantly longer for group 1 as compared with group 2 (6.9 vs 5.7 week; P < 0.05). Following cradle use, group 1 infants demonstrated a significantly larger change in TCD in comparison to group 2 (change in TCD: 6.0 vs 4.0 mm; P < 0.001). At the conclusion of therapy, group 1 infants trended toward greater calvarial symmetry than group 2 patients (final TCD: 4.5 vs 5.0 mm; P = 0.06) and a higher frequency of cases with full correction of asymmetry (62.4% vs 52.2%; P = 0.16). CONCLUSIONS: The Plagio Cradle can fully correct deformational plagiocephaly early in life. Nevertheless, treatment is more effective if initiated before 10 weeks of age.

Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction.

BACKGROUND: The purpose of this study was to evaluate the relationship between age at initiation of helmet therapy for deformational plagiocephaly and the rate of correction. METHODS: Infants treated for deformational plagiocephaly with a helmet orthosis between 2009 and 2010 were included. Patients were stratified prospectively by the age at which treatment was initiated: group 1, younger than 20 weeks (n = 26); group 2, 20 to 23.9 weeks (n = 59); group 3, 24 to 27.9 weeks (n = 82); group 4, 28 to 31.9 weeks (n = 62); group 5, 32 to 35.9 weeks (n = 45); group 6, 36 to 40 weeks (n = 29), and group 7, older than 40 weeks (n = 43). Pretreatment and posttreatment calvarial asymmetry was measured using direct anthropometry and reported as a transcranial difference. RESULTS: Three hundred forty-six infants were included; initial transcranial difference was equivalent on all paired-group comparisons. Duration of helmet therapy positively correlated with age at initiation (r = 0.89, p < 0.05). The rate of change in transcranial difference correlated negatively with age at treatment onset (r = -0.88, p < 0.05): group 1, 0.93 mm/week; group 2, 0.64 mm/week; group 3, 0.59 mm/week; group 4, 0.56 mm/week; group 5, 0.41 mm/week; group 6, 0.42 mm/week; and group 7, 0.42 mm/week). At the conclusion of therapy, all groups had improved calvarial symmetry, albeit less completely in groups 6 and 7. CONCLUSIONS: The correction rate of plagiocephaly with helmet therapy decreases with increasing infant age; after 32 weeks, there is a slow and relatively constant rate of change. Improvement can still be achieved in infants older than 12 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Bilateral versus unilateral bronchoalveolar lavage for the diagnosis of ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia (VAP) complicates the clinical course of critically injured intubated patients. Bronchoscopic bronchoalveolar lavage (BAL) represents an invasive and accurate means of VAP diagnosis. Unilateral and blinded techniques offer less invasive alternatives to bronchoscopic BAL. This study evaluated clinical criteria as well as unilateral directed versus bilateral BAL for VAP diagnosis. METHODS: A retrospective chart review of 113 consecutive intubated trauma patients with clinically suspected VAP undergoing unilateral versus bilateral BAL was performed with comparison of positive culture results (>10(4) colony-forming units [CFU]/mL). Culture results were compared with chest radiograph (CXR) infiltrates and white blood cell (WBC) count elevation. RESULTS: Bilateral BAL was more likely to be positive than unilateral BAL (50.4% vs. 25.5%). In 37.1% of bilateral BALs, there was discordance between the sides of positivity or the bacteria isolated. A CXR infiltrate and WBC count elevation did not predict positive BAL. CONCLUSIONS: Clinical indicators of VAP are inaccurate, and bilateral bronchoscopic BAL is more likely than unilateral BAL to provide a positive sample in intubated trauma patients. Techniques that do not sample both lungs reliably should be avoided for diagnosis in this patient population.