Incidence of Intraoperative Cardiothoracic Intervention During Open Surgery Following Acute Posterior Sternoclavicular Joint Injury: A Case Series and Review of the Literature.

BACKGROUND: Acute posterior sternoclavicular joint injuries are rare but potentially lethal injuries-signs of mediastinal compression range from nonspecific to neurovascular compromise. Currently, orthopaedic experts recommend a cardiothoracic surgeon be placed on standby during open surgery for potential intraoperative complications. However, few studies have reported on how often cardiothoracic intervention is required. METHODS: First, we identified patients in our institution by CPT codes 23530, 23525, and 23532 from January 1, 2002 to May 1, 2023. Demographic variables and intraoperative cardiothoracic intervention rates were collected. Second, we systematically reviewed the literature to identify articles on acute posterior sternoclavicular injury using PubMed, Embase, and CINAHL databases (through August 20, 2023). Exclusion criteria included conservative treatment, successful closed reduction, chronic injury (>6 wk) cadaver studies, reviews, and nonavailable text. RESULTS: Thirteen local patients underwent open surgery for an acute posterior sternoclavicular joint injury, 11 males and 2 females with an average age of 18.2 years old (range: 15 to 32.4). The most common mechanism of injury was sports (n=9; 69.2%). Four (30.8%) patients had physical or radiographic evidence of mediastinal compression. No patients required intraoperative cardiothoracic intervention in our institution. The literature search yielded 132 articles and 512 open surgeries for acute posterior sternoclavicular joint injuries. Four patients required intraoperative cardiothoracic intervention, all of whom presented with polytrauma and/or clinical or radiographic signs of neurovascular compromise, giving a combined overall rate of 0.76%. CONCLUSIONS: Expert opinion commonly recommends cardiothoracic backup during open surgery for acute posterior sternoclavicular joint injuries. On the basis of our local data and systematic literature review, we found an overall cardiothoracic intervention rate of 0.76%. In the presence of polytrauma and/or findings of neurovascular compromise, we suggest having cardiothoracic surgery on close standby during the procedure. However, a patient with an isolated acute posterior sternoclavicular joint injury and no clinical or radiographic findings of neurovascular compromise does not appear to require a cardiothoracic surgeon on standby. Ultimately, the decision to involve cardiothoracic backup during open surgery for an acute posterior sternoclavicular injury should be made on a case-by-case basis after a thorough physical and radiographic evaluation of the patient. LEVEL OF EVIDENCE: Level III.

A Readability Analysis of Online Spondylolisthesis and Spondylolysis Patient Resources Among Pediatric Hospital Web Pages: A US-Based Study.

INTRODUCTION: With the increasing use of the internet for health information, it is essential to prioritize resources that match the reading level of patients and parents. Limited health literacy is a notable issue in the United States, creating a financial burden and negatively affecting patient outcomes. This study aimed to assess the availability and readability of pediatric hospital web pages concerning two prevalent spine conditions in children, spondylolisthesis and spondylolysis, specifically examining whether the available resources meet the recommended sixth grade reading level. METHODS: A total of 179 pediatric hospital web pages were assessed for their availability and readability of spondylolisthesis and spondylolysis patient information. The web pages' readability was assessed using five readability formulae. Descriptive statistics and Student t-tests were performed on the collected scores with significance set at P < 0.05. RESULTS: Among the analyzed hospitals, 40.2% had no information on spondylolisthesis or spondylolysis, 20.1% mentioned treating these conditions, 7.8% had < 100 dedicated words, and only 31.8% had dedicated web pages with more than 100 words on these conditions. The average reading grade level for the evaluated web pages was 12.0, indicating a high school education level is required for comprehension. None of the web pages were written below the recommended sixth grade reading level. DISCUSSION: The readability of the limited resources was markedly higher than the recommended reading level. In addition, this study emphasizes the need for enhanced accessibility and readability of online patient information from pediatric hospitals to improve parental comprehension and informed decision-making. Physicians should consider identifying online resources that they consider of high quality and acceptable readability to support better patient understanding and outcomes.

Are Postcast Removal X-rays and a Second Follow-up Necessary in the Treatment of Nondisplaced Supracondylar Humerus Fractures?

BACKGROUND: The utility of routine follow-up radiographs for the treatment of nondisplaced pediatric supracondylar humerus fractures has not been established. The purpose of this study is to (1) determine the frequency that postcast removal x-rays change patient management and (2) determine the role of routine follow-up for range of motion evaluation after cast removal in the treatment of nondisplaced supracondylar humerus fractures. METHODS: We conducted a single center retrospective chart review of patients under the age of 18 years old that sustained nondisplaced supracondylar humerus fractures between January 1, 2010 and July 1, 2018. Demographic information, fracture characteristics, time to follow-up and each appointment outcome were recorded. A change in patient management after postcast removal x-ray was defined as a need for an additional period of immobilization, a delay in initiation of range of motion exercises, or need for operative intervention. In addition, the appointment for range of motion evaluation was considered to alter management if further activity restriction was required, a formal physical therapy program was recommended or an additional office visit required. Unscheduled appointments were also noted. RESULTS: A total of 489 patients met inclusion criteria. The average age was 4.90±2.68 years and 51.8% were female. A total of 487 patients had routine follow-up x-rays after cast removal. No patient had a change of management based on postcast removal radiographs. In all, 290 patients returned for range of motion follow-up with 94.8% of patients being discharged from care. There were 14 patients whose management changed based on this evaluation (4.8%). The most common reason was an additional appointment for range of motion evaluation (12/14 patients, 86%). There were 13 patients with unscheduled evaluation after discharge from care, 77% were secondary to repeat injury. CONCLUSION: This study suggests that postcast removal x-rays and routine follow-up after cast removal rarely change patient management and may not be necessary in the treatment of nondisplaced pediatric supracondylar humerus fractures. LEVEL OF EVIDENCE: Level IV-case series.

Postoperative radiographic observations following transphyseal anterior cruciate ligament reconstruction in skeletally immature patients.

OBJECTIVE: To characterize the changes to bone tunnels, graft fixation devices, and physes that occur on radiographs of skeletally immature individuals at least 2 years after transphyseal anterior cruciate ligament reconstruction (ACLR). MATERIALS AND METHODS: Skeletally immature patients who underwent transphyseal ACLR were recruited to complete postoperative assessment at ≥ 2 years. The dimensions of tibial and femoral bone tunnels, position of graft fixation devices, and presence of growth arrest were assessed on radiographs, and pain visual analog and International Knee Documentation Committee scores were obtained. Paired t tests were used for comparisons. RESULTS: Nine patients were included with an average follow-up of 4.6 years postoperatively. There were no cases of premature physeal closure postoperatively and clinical outcome measures were excellent in all patients. The length of the intra-articular portion of anterior cruciate ligament graft increased postoperatively (P = 0.01). Distance between the tibial hardware and proximal tibial physis also increased over time on anteroposterior (P = 0.001) and lateral (P = 0.003) radiographs. However, the distance between the femoral hardware and distal femoral physis was unchanged and in five patients was associated with proximal femoral tunnel enlargement. CONCLUSION: Proximal femoral tunnel expansion and lack of proximal migration of the femoral button were seen in more than half of our patients. However, these findings had no detrimental effects on clinical outcome measures or remaining skeletal growth.

Transphyseal Femoral Neck Fracture in a Twenty-Month Old Male Child.

Transphyseal femoral neck fractures are an extremely rare event, mainly occurring in children subjected to an significant traumatic force. The diagnosis is usually suggested by clinical examination with radiographic confirmation. Management varies; however, no consensus exists as to proper treatment. Intervention is primarily focused on the prevention of avascular necrosis (AVN) of the femoral epiphysis. We present the case of a 20-month-old male with a delayed diagnosis of transphyseal femoral neck fracture. X-ray (XR) and computed tomography (CT) scan images were used for diagnosis, to track healing, and monitor the possible emergence of avascular necrosis. Final imaging demonstrated full healing without AVN at two years. This study demonstrates the successful treatment of a rare pediatric fracture type with possible life-changing complications. Reduction, surgical fixation with K-wires, and spica casting are demonstrated as being acceptable treatment in the very young transphyseal fracture patient.

Outcomes of operative versus nonoperative treatment of displaced pediatric clavicle fractures.

Current literature proposes relative and absolute indications for surgical treatment of clavicle fractures in adults. However, few studies have evaluated these fractures in children. The current study examined short- and long-term outcomes of pediatric patients with displaced clavicle fractures. Outcomes assessed included radiographic healing, full active range of motion, and return to activity. The authors' hypothesis was that open reduction and internal fixation of displaced clavicle fractures would lead to better outcomes than nonoperative treatment. The authors retrospectively reviewed the charts of pediatric patients treated for clavicle fractures between January 2001 and October 2011. The nonoperative group included 32 patients, and the operative group included 46 patients. Mean time to return to activity was 12.24 weeks in the nonoperative group and 12.70 weeks in the operative group (P=.67). Mean time to full active range of motion was 7.85 weeks in the nonoperative group and 8.74 weeks in the operative group (P=.24). Mean time to radiographic evidence of healing was 12.02 weeks in the nonoperative group and 11.90 weeks in the operative group (P=.90). Average Disabilities of the Arm, Shoulder and Hand (DASH) score was 0.04 in the nonoperative group (range, 0-0.08) and 1.17 in the operative group (range, 0-8.3), with no significant difference between groups. No significant difference between operative treatment and nonoperative treatment was found in any of the authors' outcome measures. Thus, the authors propose that unless the patient's injury is an absolute indication for surgery, conservative management provides equivalent immediate and long-term clinical results.

Brace treatment resulting in overcorrection of adolescent idiopathic scoliosis.

Brace treatment for idiopathic scoliosis in skeletally immature children is the only effective nonoperative modality for the control of curve progression. The Charleston bending brace is a custom-molded spinal orthosis that holds the patient in a completely corrected or overcorrected position while worn at night. A 9-year-old girl presented with 10° right upper thoracic and 7° left lower thoracic curves and was Risser sign 0. Nighttime treatment with a Charleston bending brace was initiated when the left lower thoracic curve progressed to 19°. After 27 months of nighttime brace wear, the lower thoracic curve was 21° to the right. Further investigation, including magnetic resonance imaging of the spine, failed to diagnose an identifiable explanation for this atypical occurrence. Conservative treatment may improve radiographic and cosmetic appearance. Overcorrection of the curve, although not likely, is possible when part-time or nighttime bracing is implemented as a means of conservative management.

Nonoperative management of pediatric grade 1 open fractures with less than a 24-hour admission.

BACKGROUND: The purpose of this study was to evaluate the results of nonoperative management of pediatric grade 1 open fractures treated either in the emergency room only or with a less than 24-hour admission. METHODS: A retrospective chart review was done on all patients with this type of injury who were treated by nonoperative modalities in the emergency room and who were admitted for no more than 24 hours for administration of intravenously administered antibiotics. Our population included 25 patients who were followed up until healing was confirmed clinically and radiographically. RESULTS: One patient with persistent serosanguineous drainage from the wound site and fever was admitted for 48 hours of intravenously administered antibiotics for presumed infection. That patient went on to heal both clinically and radiographically without further complication. Therefore, our infection rate was 4.0%. CONCLUSIONS: This study demonstrates the safe nonoperative treatment of grade 1 open fractures in our pediatric population. This management eliminates any possible anesthetic risk as well as significantly decreases the cost of caring for these patients in the health care system.

Correction of non-Blount's angular knee deformity by permanent hemiepiphyseodesis.

This retrospective study evaluated the results of permanent hemiepiphyseodesis for the correction of non-Blount's coronal plane angular knee deformity. The medical records and radiographs of 75 patients with 125 angular knee deformities were analyzed for overall rate of success and factors predicting successful correction of deformity. There were 38 patients with idiopathic genu valgum and 37 with various other skeletal disorders. Sixty-nine out of 75 patients had reached skeletal maturity at latest follow-up. One hundred six knees out of 125 were successfully treated by the procedure. Of the 19 remaining knees, 15 were operated on too close to skeletal maturity to expect correction and 4 were technically unsuccessful in achieving closure of the targeted physis. There were no complications other than overcorrection, which occurred in 15 knees (11 patients). This study indicates that permanent hemiepiphyseodesis is a very useful procedure if performed in a timely and technically successful manner.