K-wire Versus Screw Fixation in Displaced Lateral Condyle Fractures of the Humerus in Children: A Multicenter Study of 762 Fractures.

INTRODUCTION: Lateral humeral condyle fractures account for 12% to 20% of all distal humerus fractures in the pediatric population. When surgery is indicated, fixation may be achieved with either Kirschner-wires or screws. The literature comparing the outcomes of these 2 different fixation methods is currently limited. The purpose of this study is to compare both the complication and union rates of these 2 forms of operative treatment in a multicenter cohort of children with lateral humeral condyle fractures. METHODS: This retrospective study was performed across 6 different institutions. Data were retrospectively collected preoperatively and 6 weeks, 3, 6, and 12 months postoperatively. Patients were divided into 2 cohorts based on the type of initial treatment: K-wire fixation and screw fixation. Statistical comparisons between these 2 cohorts were performed with an alpha of 0.05. RESULTS: There were 762 patients included in this study, 72.6% (n=553) of which were treated with K-wire fixation. The mean duration of immobilization was 5 weeks in both cohorts, and most patients in this study demonstrated radiographic healing by 11 weeks postoperatively, regardless of treatment method. Similar reoperation rates were seen among those treated with K-wires and screws (5.6% vs. 4.3%, P =0.473). Elbow stiffness requiring further intervention with physical therapy was significantly more common in those treated with K-wires compared with children treated with screws (21.2% vs. 13.9%, P =0.023) as was superficial skin infection (3.8% vs. 0%, P =0.002), but there was no significant difference in nonunion rates between the two groups (2.4% vs. 1.3%, P =1.000). CONCLUSION: We found similar success rates between K-wire and screw fixation in this patient population. Contrary to previous studies, we did not find evidence that treatment with screw fixation decreases the likelihood of experiencing nonunion. However, given the unique complications associated with K-wire fixation, such as elbow stiffness and superficial skin infection, the treatment with screw fixation remains a reasonable alternative to K-wire fixation in these patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Open Reduction and Internal Screw Fixation of Transitional Ankle Fractures in Adolescents.

A triplane fracture is an example of a transitional fracture of adolescence that occurs because the distal tibial physis closes in a predictably asymmetric way from central to medial and then lateral. The triplane fracture is so named because the fracture lines propagate in 3 planes (axial, sagittal, and coronal) and thus appear on radiographs as a Salter-Harris III pattern on anteroposterior images and Salter-Harris II or IV on lateral images. The fracture occurs via a twisting mechanism (usually supination and external rotation) through the relatively weak open portion of the physis (axial) and propagates out the metaphysis (coronal) and/or epiphysis (sagittal) at the transition to the relatively stronger closed portion of the physis. Because the distal tibial physis closes over approximately an 18-month period in female patients from 12 to 14 years old and male patients from 13 to 15 years old, this is the age range in which triplane fractures occur. Triplane fractures account for approximately 5% to 10% of pediatric ankle fractures. The purpose of the present video article is to review the indications for operative treatment of transitional ankle fractures in adolescents and to detail the surgical technique specifically for open reduction and screw fixation of triplane fractures. The procedure is performed in order to provide anatomic reduction of the fracture and rigid fixation. Description: Surgical treatment of a triplane fracture is indicated if there is >2 mm articular displacement of the distal aspect of the tibia or if the fracture pattern is deemed unstable following closed reduction and casting. Preoperative planning (Step 1) involves the use of radiographs and computed tomography scans to determine accurate fracture classification, the intended reduction maneuver, possible blocks to reduction, and screw trajectory and length. Room setup and patient positioning (Step 2) include placing the patient in the supine position with a bump under the hip, as well as the placement of a ramp or stack of blankets under the affected limb and adequate general anesthesia with muscle relaxation to facilitate reduction. Incision and surgical exposure (Step 3) is performed with use of an anterior ankle incision at the anatomic plane between the extensor hallucis longus and extensor digitorum longus, protecting the neurovascular bundle (i.e., the anterior tibial artery and deep peroneal nerve). Open reduction and assessment of reduction (Step 4) begins by removing any soft tissue, such as the periosteum, that may be interposed in the fracture site precluding a reduction. The ankle is then put through internal rotation and dorsiflexion in order to reduce the fracture, utilizing direct visualization through the incision and fluoroscopy to verify reduction with <2 mm articular step-off. Screw placement (Step 5) typically involves a 2-screw construct, with 1 screw starting at the anterolateral distal tibial epiphysis aiming medially (and staying within the epiphysis) and a metaphyseal screw aiming from the anterior metaphysis to the posterior Thurston-Holland fragment. Closure and immobilization (Step 6) usually involve a layered skin closure, as no deep closure is necessary in most cases. A below-the-knee cast is applied with the ankle in neutral dorsiflexion. Alternatives: Nonoperative treatment typically involves closed reduction and long-leg cast immobilization. Rationale: Surgical treatment with reduction and screw fixation of triplane fractures is indicated for patients with >2 mm articular displacement or >3 mm physeal displacement of the distal aspect of the tibia. Achieving and maintaining reduction with screw fixation within these tolerances helps decrease the chance of arthritis development by 5 to 13 years postoperatively5,7. Expected Outcomes: Following treatment of a triplane fracture with reduction and screw fixation, full ankle range of motion and normal growth are anticipated. Postoperative follow-up continues until skeletal maturity or until 1 year postoperatively with evidence of continued growth by Park-Harris lines on sequential radiographs. Short-term recovery is expected to be excellent, and long-term results are expected to be good as long as <2 mm articular reduction is achieved and maintained5,7. Important Tips: General anesthesia with muscle relaxation helps with closed or open reduction.Computed tomography is valuable for determining the maximum articular displacement and for 3D surgical planning for screw trajectories.Be aware of the periosteum and perichondrial ring as possible soft-tissue blocks to reduction, and do not hesitate to visualize the periosteum with an open technique to achieve anatomic reduction. Acronyms and Abbreviations: AITFL = anterior inferior tibiofibular ligamentAP = anteroposteriorCT = computed tomography.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Pediatric Proximal Radial Shaft Fractures Treated Nonoperatively Fail to Maintain Acceptable Reduction up to 70% of the Time.

OBJECTIVE: To compare early radiographic malalignment rates of conservatively treated proximal radial shaft fractures to more distal fractures. DESIGN: Retrospective cohort study. SETTING: A pediatric, Level 1 trauma center. PATIENTS/PARTICIPANTS: We identified a group of 401 pediatric patients who were treated for a complete radial shaft fracture at our institution. Of this group, 309 patients met our inclusion criteria for attempted nonoperative management and were evaluated in our study. INTERVENTION: Closed reduction and casting. MAIN OUTCOME MEASUREMENT: The primary outcome of the study was the failure rate of nonoperative management as defined by residual angulation of the radius assessed on follow-up radiographs. RESULTS: Proximal third fractures were significantly more likely to fail conservative treatment (P < 0.0001) as they exceeded angulation criteria 70% (32/46) of the time compared with more distal fractures (33%; 87/263). In terms of halves (P = 0.0003), the proximal half fractures failed 50% (55/111) of the time while 29% (57/198) of distal half fractures failed conservative treatment. Failure of closed reduction and casting was 4.6 times higher (95% confidence interval, 2.3-9.1) in proximal third fractures and 2.4 times greater (95% confidence interval, 1.5-3.9) in proximal half fractures compared with their more distal counterparts. CONCLUSIONS: Given the impressive rate of failure of closed reduction and casting of proximal third radial shaft fractures, the treating orthopaedic surgeon should prudently consider all management options. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Foot Fracture Pearls and Pitfalls.

Although foot fractures are relatively rare in children, they deserve respect and attention because they may be associated with troublesome long-term consequences. These injuries are more common in adolescents and teenagers. In an epidemiological study in Britain (Cooper et al 2004), the incidence of pediatric foot fractures was 10.5 per 10,000 children occurring equally in boys and girls and peaking around 13 years of age. This article focuses on 5 fracture types which are at higher risk of complications in the pediatric and adolescent age group.

Complications of Pediatric Foot and Ankle Fractures.

Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.

The use of ultrasound in the management of septic arthritis of the hip.

In the assessment of septic arthritis of the hip in a pediatric population, ultrasound is a safe and easily conducted method to confirm an effusion. The need for MRI to further evaluate the patient for adjacent infection before treatment is debatable. Once an effusion is confirmed on ultrasonography, we have found that septic arthritis of the hip does not need advanced imaging before arthrotomy and debridement. Patients who fail to clinically respond to an initial hip arthrotomy and appropriate antibiotics may benefit from an MRI for the identification of concomitant infections that may require surgical intervention.

Intrathecal Anomalies in Presumed Infantile Idiopathic Scoliosis: When Is MRI Necessary?

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the rate of abnormal magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS) and the rate of neurosurgical intervention in those patients, and to develop a guideline concerning when to obtain an MRI. SUMMARY OF BACKGROUND DATA: The reported rate of intrathecal anomalies associated with presumed IIS varies in the literature (12% to 50%). Conclusions have led to conflicting recommendations concerning when an MRI is indicated. METHODS: After appropriate internal review board approval, the authors retrospectively reviewed the medical records of patients from a single institution meeting the inclusion criteria: presumed idiopathic curve with a magnitude of ≥20°, age <36 months at diagnosis, normal neurologic examination, and presentation between 2002 and 2010. The authors reviewed the MRI findings, whether neurosurgical intervention took place, and the orthopedic treatment course (observation, brace, cast, or surgery). RESULTS: A total of 56 patients were identified and reviewed; 43 had had an MRI. Seven of 43 patients were found to have an anomaly (16.2%). A fatty filum was identified in 2 patients, a syrinx in 3, Chiari I malformation in 2, and a tethered cord in 1 (this patient also had a syrinx). Two of the 7 patients required neurosurgical intervention (28%). Patients who did not have an MRI were statistically younger, had smaller Cobb angles, and required less orthopedic treatment. CONCLUSIONS: The incidence of intrathecal anomalies (16.2%) at the authors' institution was similar to previously published reports; however, the need for neurosurgical intervention was significantly lower in this study (28%). For younger patients with small curves (<30°) who do not require orthopedic treatment, MRI under sedation can be delayed or avoided. Clinical judgment should be the determinant for whether to use MRI when evaluating patients with presumed IIS.

Serial casting as a delay tactic in the treatment of moderate-to-severe early-onset scoliosis.

BACKGROUND: Serial casting can cure mild infantile idiopathic scoliosis. Its use in delaying surgery in older children and those with larger curves or syndromes is poorly defined. METHODS: A review of a single center's experience with casting was performed. Patients were included if they had a syndromic, neuromuscular, or congenital scoliosis or were older than 2.5 years with an idiopathic scoliosis measuring >50 degrees. RESULTS: A retrospective review was performed on 29 patients meeting all inclusion criteria. Of these, 12 were idiopathic and 17 were nonidiopathic curves. Average age at first cast was 4.4 ± 2.1 years, and 3.0 ± 1.8 cast changes were performed over 1.4 ± 1.1 years. Patients were transitioned to a brace and followed up for 5.5 years (range, 2.2 to 11.4 y). The main thoracic Cobb angle before casting was 68.8 ± 12.3 degrees, which corrected to 39.1 ± 16.4 degrees in a cast. Cobb angle after cast removal was 60.9 ± 18.4 degrees, which increased to 76.3 ± 24.0 degrees at final follow-up. T1-T12 height increased to 1.1 ± 2.6 cm during the treatment period (P=0.05). There were 5 minor complications. Fifteen patients (51.7%) required surgical treatment for their scoliosis at most recent follow-up and an additional 7 patients (24.1%) were delayed until a definitive anterior/posterior spinal fusion could be performed. Surgery was delayed 39 ± 25 months from the first cast. Growing rods were required in 8 patients (27.6%). The patients who ultimately underwent surgical intervention (SG) were more likely to have a larger postcasting residual main thoracic Cobb angle than those who did not require surgery [NS; 69.5 ± 14.6 degrees (SG) vs. 51.6 ± 17.9 degrees (NS), P=0.007] and had a greater progression of their curves after cast removal [20.9 ± 13.5 degrees (SG) vs. 9.4 ± 11.0 degrees (NS), P=0.02]. CONCLUSIONS: Serial casting is a viable alternative to surgical growth sparing techniques in moderate-to-severe early-onset scoliosis and may help delay eventual surgical intervention. Although a cure cannot be expected, an average of 39 months of delay was achieved in this patient cohort and 72.4% have avoided growing spine surgery. LEVEL OF EVIDENCE: Level IV, case series.