Reliability of a modified Gartland classification of supracondylar humerus fractures.

Fracture-classification systems are used to recommend treatment and predict outcomes. In this study, a modified Gartland classification system of supracondylar humerus fractures in children was assessed for intraobserver and interobserver variability. Five observers classified radiographs of 50 consecutive children with extension supracondylar humerus fractures on three separate occasions. After a 2-week interval, 90% of fractures were classified the same on both readings, with and intraobserver kappa value of 0.84. After a 36-week interval, 89% of the fractures were classified the same, with a kappa value of 0.81. Interobserver reliability was evaluated by pairwise comparison among observers, resulting in an overall kappa value of 0.74. The reliability of the Gartland classification for supracondylar humerus fractures in children is better than that published for other fracture-classification systems. However, 10% of the time, a second reading by the same observer is different. This makes treatment recommendations based only on fracture type imprecise.

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures.

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).

Brace treatment of early infantile tibia vara.

We reviewed 24 children (42 extremities) who had a diagnosis of early infantile tibia vara treated by using a brace. The indication for bracing was either a varus deformity that was not improving by age 18-24 months, or a persistent varus deformity seen in a patient older than 24 months. We prescribed an above-the-knee brace with a free ankle, single medial upright with valgus-producing straps, and either no hinged joint or a locked hinge joint at the knee. The braces were worn during the day and were removed for bedtime. The patients were followed up for an average of 27.2 months (range, 12-72) from the initiation of brace treatment, and the outcome at latest follow-up was determined by using radiographic criteria. Before treatment, 29 extremities were Langenskiöld stage I, II were stage II, and two were stage III. Before treatment, the metaphyseal-diaphyseal angle averaged 16.4 degrees. Forty of the 42 extremities had metaphyseal-diaphyseal angles of > 11 degrees, and 20 were > 16 degrees. Based on our criteria, we rated 29 extremities good, nine fair, and four poor. We conclude that daytime, ambulatory brace treatment may favorably alter the natural history of tibia vara in patients who are younger than 3 years and who have Langenskiöld stage I or II deformity.