Musculoskeletal Manifestations of Child Abuse: Analysis at a Level 2 Trauma Center in Puerto Rico.

OBJECTIVE: To describe the epidemiological manifestations and assess major risk factors in children under the age of three years presenting with non-accidental injury (NAI) fractures in a level two trauma center in Puerto Rico. METHODS: An IRB approved retrospective descriptive study was performed by reviewing case records of 75 patients who presented with a NAI fracture at the Pediatric University Hospital of the Puerto Rico Medical Center. The study time period was from October 1996 to October 2014. The inclusion criteria for our population consisted of: (1) patients between the ages of zero to three years, (2) suffered a long bone fracture, and (3) had a history of suspected child abuse at our academic institution. The exclusion criteria were: (1) patients older than three years, (2) no history of NAI, or (3) had a congenital bone disorder. RESULTS: A total of 117 long bone fractures were observed in our population. Similar distribution was seen between sex,, with 52% being male and 48% being female. The mean age was 10.8 months. The group with the highest frequency of NAI fractures were children under the age of one year (57.3 %). The most commonly involved fractured bone for all age groups was the femur (48.0 %). No statistical significance was observed when comparing sex, age, associated injuries or multiple fractures. CONCLUSION: Children younger than one year of age who present with long bone fracture, multiple fractures, low household income and parental unemployment are associated with an increased risk of NAI fractures.

FINGERTIP RECONSTRUCTION WITH THE "SHARK MOUTH" INCISION THENAR FLAP: ANALYSIS OF OUTCOMES IN PEDIATRIC PATIENTS.

UNLABELLED: The thenar flap technique is a time-tested method of fingertip reconstruction that has been criticized due to possible finger flexion contractures and unsightly donor site scars. Functional outcome data on thenar flaps on the pediatric population is poor in the medical literature. METHOD: In this retrospective chart review we acquired information from sixteen patients who underwent a "Shark Bite" incision thenar flap reconstruction. RESULTS: Patients ranged in age from 0-17 years. Time to division ranged from 16-30 days. All 16 patients' affected finger ROM were measured in DIP, PIP and MCP joints and compared with corresponding finger on contralateral hand. A questionnaire measured subjective satisfaction in: sensibility, appearance, and function. Fingertip sensation was preserved in both affected finger and donor site. The most persistent patient complaint involved fingertip contour, were most patients rated it as "Fair"(43%) and "Good" (56%). After statistical analysis of the data we found no statistical difference in range of motion (ROM) between affected finger and the same finger on the contralateral hand on both PIP and MCP joints (p=0.08, 0.06 respectively). CONCLUSIONS: The "Shark Mouth" incision thenar flap is an effective strategy for fingertip reconstruction. The results demonstrate this technique has excellent functional and aesthetic results and is not associated with flexion contractures, excessive sensibility or pain in the pediatric population.

Hemostatic matrix application after open synovectomy in a hemophilic patient.

Recurrent, spontaneous bleeding is common in patients with hemophilia. The joints are commonly and repeatedly affected, and this can result in chronic synovitis and joint damage. Synoviorthesis or synovectomy are indicated after failure of appropriate medical management. Hemostasis in the perioperative period is paramount in these patients. We report a case study of a patient with hemophilia A inhibitors undergoing open synovectomy complicated by postoperative bleeding. In addition to an infusion of bypassing agents due to the presence of inhibitors, a topical hemostatic agent, FLOSEAL, and absorbable Gelfoam were applied. Hemostasis was achieved rapidly. The patient recovered without complications.

Arbona system reengineered in the Garcia-Ariz Model: a national health reform plan from an orthopedics program perspective.

During the 1950's the healthcare system of Puerto Rico was maintained exclusively by the local government. The Arbona system, as it came to be known, although it provided health care professionals on the island with multiple educational experiences, presented substantial costs for the government. In the early 1990's a program of privatization known as "La Reforma" was implemented with the ultimate goal of providing a universal coverage system for the poor and the needy. At present this program has brought other issues regarding the quality of medical services and loss of academic centers. This is a preliminary report that analyzes various aspects of both systems through the search and analysis of background resources and literature, interviews, and physician/patient satisfaction surveys (on working conditions and quality of services). The main purpose of this report is to create a model that proves to be efficient and coherent with the island's idiosyncrasies.