Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?

Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.

Reducción de fracturas nasales con anestesia local. Nuestra experiencia / Reduction of nasal fracture with local anesthesia. Our experience / Redução de fratura nasal com anestesia local. A nossa experiência

Introducción: las fracturas nasales son la consecuencia más frecuente de los traumatismos craneofaciales. Su tratamiento puede involucrar una reducción cerrada de huesos propios nasales que puede realizarse con anestesia local. El objetivo del presente trabajo es evaluar los resultados funcionales, estéticos y el dolor en la reducción cerrada de fracturas nasales. Material y método: Estudio prospectivo, randomizado, y descriptivo que evaluó la funcionalidad nasal antes y después de la reducción, en dolor del procedimiento, y sus resultados estéticos. Resultados: Se realizaron un total de 21 reducciones cerradas. El signo más habitual fue la crepitación en 14 pacientes, laterorrinia en 13, y 4 epistaxis. En cuanto a ventilación nasal previo a la reducción, el máximo puntaje en la escala Nasal Obstruction Symptoms Scale fue de 13 puntos, con un promedio de 4,8 puntos; y luego de realizar la reducción nasal el puntaje más alto fue de 7, con un promedio de 1,09 puntos. Estéticamente, luego de realizar la reducción nasal 8 pacientes notaron que su nariz estaba "mucho mejor", 9 pacientes notaron que su nariz estaba "mejor", y 4 pacientes indicaron que estaba igual. En cuanto a eficacia anestésica el menor puntaje fue de 0 referido por tres pacientes, el más alto fue de 10 en 2 pacientes; y el puntaje promedio referido fue de 3,5. Conclusiones: La reducción cerrada de fractura nasal es una técnica que es posible de realizar bajo anestesia local, obteniendo óptimos resultados estéticos y funcionales, y siendo bien tolerada por el paciente si la técnica se hace adecuadamente. Es necesario contar con la experiencia y los medios necesarios para realizarla.

Introduction: nasal fractures are the most frequent consequence of craniofacial trauma. Its treatment may involve a closed reduction of nasal bones that can be performed under local anesthesia. The objective of the present study is to evaluate the functional, aesthetic and pain outcomes in the closed reduction of nasal fractures. Material and method: Prospective, randomized, and descriptive study, evaluating nasal function before and after reduction, the pain of the procedure, and its aesthetic results. Results: A total of 21 nasal fracture reduction were made closed. The most common sign was crepitus in 14 patients, laterorrinia in 13, and 4 epistaxis. As for nasal ventilation prior to reduction, the maximum score in the Nasal Obstruction Symptoms Scale was 13 points, with an average of 4.8 points; and after performing the nasal reduction the highest score was 7, with an average of 1.09 points. Aesthetically, after making the nasal reduction 8 patients noticed that his nose was "much better", 9 patients noticed that his nose was "better", and 4 patients indicated that was “same as before”. As for anesthetic efficacy was the lowest score of 0 was reported by three patients, the highest was 10 in 2 patients; and referred the average score was 3.5. Conclusions: Closed reduction of nasal fracture is a technique that can perform under local anesthesia, obtaining optimal aesthetic and functional results, and being well tolerated by the patient if the technique is done properly. You must have the experience and resources needed to perform it.

Introdução: as fraturas nasais são a consequência mais frequente dos traumas craniofaciais. Seu tratamento pode envolver uma redução fechada de ossos próprios nasais, a qual pode ser realizada com anestesia local. O objectivo deste estudo foi avaliar o resultado funcional, estética e a dor na redução de fracturas fechadas nasais. Material e método: Estudo prospectivo, randomizado e descritivo que avaliou a funcionalidade nasal antes e depois da redução, a dor do procedimento e seus resultados estéticos. Resultados: Foram realizadas 21 reduções fechadas. O sinal mais comum foi a crepitação em 14 pacientes, laterorrinia em 13 e epistaxe em 4. No tocante à ventilação nasal antes da redução, o valor máximo na escala Nasal Obstruction Symptoms Scale foi 13 pontos, com uma média de 4,8 pontos; e, após a redução nasal, o valor mais alto foi 7, com uma média de 1,09 pontos. Esteticamente, após a redução nasal, 8 pacientes notaram que seu nariz estava "muito melhor"; 9 pacientes notaram que seu nariz estava "melhor" y 4 pacientes disseram que estava igual. A respeito da eficácia anestésica, o menor valor foi 0 segundo três pacientes, e o maior foi 10 em 2 pacientes. O valor médio comentado foi 3,5. Conclusões: A redução fechada de fratura nasal é uma técnica que pode ser realizada sob anestesia local, com ótimos resultados estéticos e funcionais. É bem tolerada pelo paciente se a técnica é realizada adequadamente. É preciso contar com a experiência e os meios necessários para realizá-la.

Childhood Obesity Increases the Risk of Failure in the Treatment of Distal Forearm Fractures.

BACKGROUND: Childhood obesity is a national problem that has gained significant attention in both the medical literature and the national media. Obesity in the adult population has been associated with increased failure of conservative treatments. Our hypothesis is that childhood obesity is associated with a loss of reduction after closed treatment of distal radius fractures. METHODS: A total of 157 patients with consecutive distal radius fractures who underwent closed reduction in the emergency department or the operating room were included from the office records of the sole pediatric orthopaedic subspecialist group in a metropolitan area from January 2011 to June 2012. All cases were initially treated with fiberglass casting with or without closed reduction. All patients completed the casting treatment and demonstrated radiographic union. Patients' age, weight, height, number of office visits, subsequent surgeries, and fracture angulation were recorded and analyzed. RESULTS: Sixty-six (42%) children were overweight (BMI>85th percentile) and 46 (29%) children met the criteria for obesity (BMI>95th percentile). Fourteen normal-sized children (12%) and 13 obese children (28%) required a reduction in the operating room after initial treatment, which was significant (P=0.02). Obese children needed significantly more visits requiring radiographs (P=0.004). Obese children were significantly less likely to have an initial perfect reduction in the emergency room (P=0.005). CONCLUSIONS: The results of closed reduction and casting for displaced distal radius fractures are typically excellent with few complications or risks. The present study supports the hypothesis that obesity results in a higher rate of malreduction and subsequent manipulations with closed reduction and casting. Close follow-up and early consideration for additional treatment in this patient population may help reduce the need for further manipulations. LEVEL OF EVIDENCE: Level III.