Single bone intramedullary fixation of the ulna in pediatric both bone forearm fractures: analysis of short-term clinical and radiographic results.

BACKGROUND: Although single bone intramedullary (IM) fixation has been advocated in the treatment of unstable diaphyseal forearm fractures, some reports have questioned the ability of single bone fixation to maintain adequate reduction. The purpose of this investigation is to report the radiographic and early clinical results of single bone IM fixation for diaphyseal forearm fractures and to identify factors leading to loss of reduction of the radius after ulnar fixation. METHODS: A retrospective analysis of 38 children who underwent single bone IM fixation of the ulna for both bone forearm fractures was performed. Mean age was 9 years (range: 4-14 y). Preoperative, postoperative, and final follow-up radiographs were examined for radiographic alignment. Patient data (including age, fracture type, delay to fixation, open vs. percutaneous reduction and fixation, and time to implant removal) was collected to identify predictors for loss of reduction of the radius. Loss of reduction of the radius was defined as 10 degrees or greater change of angulation in either the frontal or lateral plane from initial postoperative radiographs to final follow-up. Multivariate analysis was used to determine associations between patient factors and loss of reduction. RESULTS: All patients went on to bony union with restoration of forearm rotation. Twenty-five patients (66%) healed with <10 degrees of angulation of the radius, whereas 11 patients (29%) had between 10 and 20 degrees of angulation at final follow-up. Two patients demonstrated greater than 20 degrees of radial angulation requiring additional surgical care. There was no statistically significant association between any patient factors and loss of radial reduction, though there was a trend for increased radial angulation in patients who had sustained open fractures. CONCLUSIONS: Single-bone IM fixation of the ulna is a safe and efficacious option for the treatment of unstable diaphyseal forearm fractures in children. Owing to the increased risk of loss of radial reduction, however, consideration should be made for IM fixation of both bones in older children and cases of open fractures. LEVEL OF EVIDENCE: IV, therapeutic.

A biomechanical study of distal interphalangeal joint subluxation after mallet fracture injury.

PURPOSE: There is no consensus in the literature regarding the size of a mallet fracture fragment that may lead to subluxation of the distal interphalangeal (DIP) joint. The purpose of this study was to determine the relationship between the size of the dorsal articular fragment and DIP joint subluxation in a cadaveric mallet fracture model. METHODS: Twenty-nine fresh-frozen fingers without evidence of DIP joint osteophytes were dissected to the metacarpal base. The mean age of the 17 donors at the time of death was 69 years (range, 46 to 89 years). Obliquely oriented fractures through the dorsal lip of the distal phalanx were randomly created with an osteotome (range, 27% to 69% of the joint surface). Each finger was fully flexed and extended 1,200 times by applying alternating tension to the flexor and extensor tendons. Fluoroscopic images were obtained and digitized for measurements of fracture fragment size and DIP joint subluxation. RESULTS: Sixteen DIP joints remained reduced and 13 distal phalanges subluxated palmarward. Subluxation was not observed when the fracture fragment measured less than 43% of the joint surface, whereas subluxation consistently occurred when the defect measured greater than 52% of the articular surface. Subluxation averaged 18% +/- 7% of the overall joint surface in these specimens. There was no correlation between the amount of joint subluxation and the percentage of articular surface damage (p = .22). CONCLUSIONS: This study supports the concept that a mallet fracture with a large articular fragment may be unstable. Palmar subluxation of a DIP joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured.

Endoscopically assisted excision of digital enchondroma.

We present 2 cases of endoscopically assisted curettage of enchondroma of the hand. After initial open curettage of the lesion, a 1.9-mm arthroscope was introduced through a small cortical window. Under arthroscopic guidance, residual pathologic material was freed from the cavity wall and evacuated with the aid of repeated saline lavage combined with suction. The saline was injected through an 18-gauge angiocatheter under direct endoscopic control. The endoscope was then used to observe the filling of the cavity with demineralized bone matrix (DBX; Synthes [USA], Paoli, PA). We believe that endoscopically assisted curettage presents several advantages over open curettage alone. First, direct visualization of the medullary canal permits accurate assessment of the extent of the enchondroma. Second, the endoscope permits accurate assessment of the adequacy of the curettage, thus avoiding the need to perform multiple, blind, and aggressive passes with a curette. Multiple passes can increase the risk of violation of the cortical shell and can prolong the procedure. Third, the ability to completely clear the medullary canal of all tumors should logically reduce the rate of recurrence. In conclusion, the addition of an endoscope is an inexpensive modification that promises to save time, decrease morbidity, and possibly improve long-term outcomes.

Coronary risk stratification in patients with end-stage lung disease.

BACKGROUND: Significant coronary artery disease (CAD) has been a contraindication for listing patients for lung transplantation. We hypothesize that coronary risk stratification can help identify a sub-set of patients who need additional diagnostic tools and intervention. METHODS: We performed a retrospective review of 72 consecutive patients who underwent lung transplantation at our institution from 1995 to 2000. Further, a review of patients who are currently listed for transplantation yielded 48 patients. We then identified the various risk factors for CAD, the diagnostic tools used, and pre-operative intervention. Risk factors identified included smoking history, diabetes, hypertension, hypercholesterolemia, CAD, congestive heart failure, age >50, and arrhythmias. Based on these risk factors, the patients were then classified into 2 groups: low risk (< or =1 risk factors) and high risk (> or =2 risk factors). We identified the patients in each group who underwent coronary angiography (CA), those with angiographic evidence of CAD, and those who received pre-operative intervention. RESULTS: Of the 72 patients who underwent lung transplantation, 48 were identified as at high risk for CAD. Of these, 5 patients had CAD diagnosed before surgery using CA, and 1 patient received pre-operative intervention. Of the 48 patients currently on the lung transplant list, we identified 28 patients as high risk for CAD, 12 of whom were noted to have CA, and 2 of whom received pre-operative intervention. CONCLUSIONS: Although CAD was once a contraindication for lung transplantation, pre-operative risk stratification allows identification of CAD with CA in a high-risk group. We believe that by using appropriate pre-operative cardiac intervention, patients with severe CAD could successfully undergo lung transplantation.