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1.
Plast Reconstr Surg ; 152(4): 662e-669e, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-36946903

RESUMO

BACKGROUND: Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries. METHODS: A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered. RESULTS: Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively). CONCLUSIONS: This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.


Assuntos
Luxações Articulares , Humanos , Masculino , Criança , Feminino , Estudos Retrospectivos , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Redução Aberta , Articulação Metacarpofalângica/diagnóstico por imagem , Articulação Metacarpofalângica/cirurgia , Articulação Metacarpofalângica/lesões , Extremidades
2.
Plast Reconstr Surg ; 146(6): 1325-1329, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33234963

RESUMO

BACKGROUND: In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. METHODS: Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. RESULTS: From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. CONCLUSIONS: Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.


Assuntos
Traumatismos do Antebraço/cirurgia , Antebraço/crescimento & desenvolvimento , Traumatismos da Mão/cirurgia , Transplante de Mão/métodos , Mãos/crescimento & desenvolvimento , Determinação da Idade pelo Esqueleto/estatística & dados numéricos , Criança , Desenvolvimento Infantil , Seguimentos , Antebraço/cirurgia , Humanos , Masculino , Estudos de Caso Único como Assunto , Resultado do Tratamento
3.
Clin Pediatr (Phila) ; 57(1): 31-35, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28110548

RESUMO

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children's hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.


Assuntos
Traumatismos em Atletas/epidemiologia , Qualidade de Produtos para o Consumidor , Veículos Off-Road/estatística & dados numéricos , Acidentes por Quedas , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados Unidos
4.
Hand (N Y) ; 13(2): 143-149, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28719991

RESUMO

BACKGROUND: Unexplained wrist pain is a common presentation in children. To our knowledge, no studies have explored the clinical utility of magnetic resonance imaging (MRI) in the diagnostic workup of pediatric patients. METHODS: We retrospectively reviewed 307 consecutive wrist MRIs ordered at a tertiary-care pediatric hospital. Demographic data and the indication for imaging were recorded and grouped into admitting categories. The final impression of each MRI was scored with regard to potential impact on future treatment (0 = normal, 1 = minimal, 2 = moderate, 3 = high). Patients who went on to wrist surgery within 1 year were noted. RESULTS: In our cohort, 27% of all studies were normal, including 34% of those with pain. Although pain was the most common category, MRI was most useful in the delineation of a mass/cyst, evaluating for infection and evaluating arthropathy. Compared with all other categories, patients with pain were 3.6 times more likely to have a normal study and 4.6 times more likely to have a clinical score less than or equal to 1. Given an admitting diagnosis of pain, females were 1.7 times more likely to present for an MRI and 2.4 times more likely to have a normal MRI. The Spearman correlation revealed no linear relationship between age and MRI outcome. In all, 13% of patients went on to have surgery within 1 year of MRI. CONCLUSIONS: At our pediatric institution, the majority of wrist MRIs were ordered for wrist pain. Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis.


Assuntos
Imageamento por Ressonância Magnética , Articulação do Punho/diagnóstico por imagem , Adolescente , Adulto , Artralgia/etiologia , Criança , Pré-Escolar , Feminino , Fraturas Ósseas/diagnóstico por imagem , Cistos Glanglionares/diagnóstico por imagem , Humanos , Lactente , Masculino , Estudos Retrospectivos , Osso Escafoide/diagnóstico por imagem , Osso Escafoide/lesões , Adulto Jovem
5.
J Hand Surg Am ; 42(5): 388.e1-388.e5, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28341068

RESUMO

PURPOSE: To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS: Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS: Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS: The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Dedos , Tenossinovite/diagnóstico , Tenossinovite/microbiologia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Resistência Microbiana a Medicamentos , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Tenossinovite/terapia , Adulto Jovem
6.
Lancet Child Adolesc Health ; 1(1): 35-44, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30169225

RESUMO

BACKGROUND: Although heterologous vascular composite allotransplantation has become a burgeoning treatment option for adult amputees, there have been no successful cases previously reported in children. Here, we describe the surgical, immunological, and neurorehabilitation details with functional outcomes 18 months after heterologous bilateral hand and forearm transplantation in an 8-year-old child with quadrimembral amputations and a previous kidney transplant. METHODS: 2 years of extensive preparation by medical and surgical teams preceded the hand-forearm transplantation of this child. The initial immunosuppressive protocol included thymoglobulin, tacrolimus, prednisone, and mycophenolate mofetil. In July, 2015, our vascularised composite allotransplantation team did the first bilateral hand and forearm transplantation in a child, an 8-year-old boy with previous living-related kidney transplantation. The surgery included four teams working simultaneously on the donor and recipient limbs, aided by customised cutting guides that aimed to reduce ischaemia time. Following an extended length of time in hospital, skin biopsies and close monitoring of renal function and drug concentrations occurred weekly for the first 3 months and were slowly tapered to monthly, and then quarterly. Skin biopsies were also done when tissue rejection was suspected. Paediatric-specific rehabilitation techniques were applied to promote patient engagement during rehabilitation. Progress was assessed by monthly sensory and motor function tests during routine clinic visits and with serial functional brain imaging studies, including structural brain MRI, magnetoencephalography and transcranial magnetic stimulation. FINDINGS: The surgery lasted 10 h and 40 min. Vascular revision of the ulnar artery was required a few hours postoperatively. There were no further immediate postsurgical complications. Rejection episodes occurred throughout the first year but were reversed. An increase in serum creatinine led to the addition of sirolimus at 3 months after transplantation with concomitant reduction in tacrolimus targets. Sensibility to light touch was present by 6 months after transplantation. Intrinsic hand muscle innervation was present by 7-10 months after transplantation. At 18 months, the child had exceeded his previous adapted abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet, and dress himself more independently and efficiently than he could do before transplantation. He remains on four immunosuppressive medications and functional neuroimaging studies have shown motor and somatosensory cortical reorganisation. INTERPRETATION: Hand transplantation in a child can be surgically, medically, and functionally successful under carefully considered circumstances. Long-term data on the functional trajectory, neurological recovery, psychological sequelae, and the potential late effect of immunosuppression are still needed to support broader implementation of paediatric vascular composite allotransplantation. FUNDING: The Children's Hospital of Philadelphia.

7.
J Pediatr Surg ; 51(8): 1370-4, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27199258

RESUMO

PURPOSE: To determine the incidence and risk factors of complications, reoperations and 30-day unplanned readmission after pediatric upper extremity surgery. METHODS: Retrospective analysis of the 2013 National Surgery Quality Improvement Program pediatric database to identify procedures that met the CPT code of a primary upper extremity procedure. A univariate and multivariate analysis was performed to identify patient- and surgery-related risk factors for complications, reoperations and 30-day unplanned readmissions. RESULTS: Upper extremity pediatric surgeries have low complication (1.70%), reoperation (0.5%) and readmission rates (0.78%). Procedures requiring reoperation, inpatient procedures, and those complicated by surgical site infection were more likely to be readmitted. Patients with complex medical histories such as cardiac disease, gastrointestinal disease, pulmonary disease, or a central nervous system disorder were more likely to be readmitted. CONCLUSIONS: Pediatric upper extremity surgery is safe and associated with low complication and readmission rates. Algorithms focusing on decreasing surgical site infection and optimizing complex pediatric medical problems may limit or further decrease complication and readmission rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Extremidade Superior/cirurgia , Criança , Pré-Escolar , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
8.
Orthopedics ; 39(2): e333-9, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26913765

RESUMO

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.


Assuntos
Traumatismos da Mão/terapia , Admissão do Paciente , Transferência de Pacientes , Encaminhamento e Consulta , Centros de Atenção Terciária , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Alta do Paciente , Estudos Retrospectivos , Centros de Traumatologia
9.
JBJS Case Connect ; 4(4): e99, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-29252767

RESUMO

CASE: We report a case of an eleven-year-old boy who presented to our clinic with a draining wound from the left elbow. He had a history of a left closed supracondylar humeral fracture that had been treated with closed reduction and percutaneous pinning at five years of age, and he subsequently developed late-onset osteomyelitis. The patient was successfully treated with surgical irrigation and debridement, followed by intravenous and oral antibiotics. CONCLUSION: Dormant osteomyelitis should be considered in the differential diagnosis for any child who presents with elbow symptoms with a prior history of a supracondylar humeral fracture that has been treated with closed reduction and percutaneous pinning.

10.
J Child Orthop ; 7(3): 225-33, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24432081

RESUMO

PURPOSE: Acute compartment syndrome (ACS) of the upper extremity is a rare but serious condition. The purpose of this study was to determine the etiology, diagnosis, treatment, and outcome of ACS of the upper extremity in a pediatric population. METHODS: We performed a retrospective chart review of all patients who underwent a decompressive fasciotomy for ACS of the upper extremity. Data collected included demographics, injury details, presenting symptoms, compartment measurements, time to diagnosis, time to treatment, and outcomes at the latest follow-up. RESULTS: Twenty-three children underwent fasciotomies for ACS of the forearm (15) and hand (8), at an average age of 9.3 years (range 0-17.8 years). The most common etiologies were fracture (13) and intravenous (IV) infiltration (3). The most common presenting symptoms were pain (83 %) and swelling (65 %). Compartment pressures were measured in 17/23 patients, and all but two patients had at least one compartment with a pressure >30 mmHg. The final two patients were diagnosed and treated for ACS based on clinical signs and symptoms. The average time from injury to fasciotomy was 32.8 h (3.7-158.0 h). Long-term outcome was excellent for 17 patients (74 %) and fair for 5 (22 %), based on the presence of loss of motor function, stiffness, or decreased sensation. One patient with brachial plexus injury and poor baseline function was excluded from functional outcome scoring. There was no association between the time from diagnosis to fasciotomy and functional outcome at the final follow-up (p = 1.000). CONCLUSIONS: Although ACS of the upper extremity in children is often associated with a long delay between injury and fasciotomy, most children still achieve excellent outcomes. The majority of patients presented with pain and at least one additional symptom, but treatment was often delayed, implying that ACS of the upper extremity in children is a difficult diagnosis to establish and may be associated with a prolonged clinical time course.

11.
J Pediatr Orthop B ; 20(5): 330-3, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21629129

RESUMO

Accurate diagnosis is crucial in effectively managing and treating both the radial and carpal fractures. Injuries to the carpal bones are not usually associated with fractures of the distal radius; however, the presence of a distal radius fracture does not preclude an associated carpal injury. The purpose of this review article is to compile cases of past reported distal radius fractures and simultaneous carpal injuries to restate its low prevalence within the pediatric population while still serving as a collective reference for management and treatment. After an electronic literature search was performed, we identified 18 published articles and 28 cases dealing with combined distal radial and carpal bones injuries in the pediatric population. As the mechanism of injury is similar for both fractures, despite the low incidence, orthopedic surgeons need to rule out carpal injury with a distal forearm fracture. Failure to treat both injuries appropriately may result in an unsatisfactory clinical result.


Assuntos
Ossos do Carpo/lesões , Traumatismo Múltiplo/diagnóstico , Fraturas do Rádio/diagnóstico , Adolescente , Moldes Cirúrgicos , Criança , Humanos , Incidência , Traumatismo Múltiplo/epidemiologia , Traumatismo Múltiplo/terapia , Prevalência , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/terapia
12.
Am J Orthop (Belle Mead NJ) ; 37(1): 47-9, 2008 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-18309385

RESUMO

There are few reports on the longevity of anterior cruciate ligament (ACL) reconstruction in adolescents. In the study reported here, we performed a survivorship analysis of our experience with ACL reconstructions in adolescents. We retrospectively reviewed the cases of 276 consecutive patients (girls' bone age, > 13 years; boys' bone age, > 14 years; chronological age, < 18 years) who underwent primary ACL reconstruction. All patients underwent transphyseal ACL reconstruction with Achilles tendon soft-tissue allograft using the same technique. Twenty-nine patients (10.5%) were excluded or lost to follow-up. Mean follow-up of the remaining 247 patients was 6.3 years (range, 2-10 years). Data were collected from charts and telephone interviews. Failure was defined as the report of symptomatic knee instability and/or revision ACL surgery. The Kaplan-Meier method showed that 1-year survivorship of ACL reconstruction was 96.4% and 5-year survivorship was 93.1%.


Assuntos
Ligamento Cruzado Anterior/cirurgia , Procedimentos de Cirurgia Plástica , Medicina Esportiva , Tendão do Calcâneo/transplante , Adolescente , Feminino , Humanos , Instabilidade Articular/etiologia , Masculino , Modalidades de Fisioterapia , Complicações Pós-Operatórias , Recuperação de Função Fisiológica , Reoperação , Estudos Retrospectivos , Transplante Homólogo
13.
Arthroscopy ; 21(9): 1144, 2005 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16171642

RESUMO

Calcified loose bodies originate in the knee joint for a variety of reasons and are removed when symptomatic. We present the case of a 56-year-old man who had multiple calcified bodies located in a sac beneath the iliotibial band known as the lateral synovial recess of the knee. Despite the fact that these loose bodies likely arose from the joint, they were unable to be visualized during arthroscopy and required a separate lateral incision for removal.


Assuntos
Calcinose/cirurgia , Cápsula Articular/cirurgia , Corpos Livres Articulares/cirurgia , Articulação do Joelho/cirurgia , Artroscopia , Calcinose/diagnóstico por imagem , Fluoroscopia , Humanos , Corpos Livres Articulares/diagnóstico por imagem , Traumatismos do Joelho/complicações , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Lesões do Menisco Tibial
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