Injuries in the competitive paediatric motocross athlete.

PURPOSE: The purpose of this study is to report the spectrum of injuries sustained by competitive paediatric motocross athletes at a level I trauma centre. PATIENTS AND METHODS: A retrospective study of paediatric competitive motocross injuries treated at a level I trauma centre between 2004 and 2014 was performed. Athletes were included if aged less than 18 years and injured while practising or competing on a competitive motocross track. Medical records were reviewed for age, gender, race, location of accident, use of safety equipment, mechanism of injury, injury type and severity, Glasgow Coma Score at hospital presentation and Injury Severity Score (ISS). RESULTS: In total, 35 athletes were studied. The average age was 14 years. One athlete died. Thirty athletes were injured during competition; five were injured during practice. Twenty-four athletes (69%) suffered an orthopaedic injury with a total of 32 fractures and two dislocations. Two fractures were open (6.3%). Lower extremity fractures were twice as common as upper extremity fractures. Surgery was more common for lower extremity fractures-83% versus 30%. The most common fractures were femoral shaft (18.8%), fibula (12.5%), clavicle (12.5%), tibial shaft (9.4%) and forearm (9.4%). CONCLUSIONS: Competitive paediatric motocross athletes suffer serious, potentially life-threatening injuries despite the required use of protective safety equipment. Femoral shaft, fibula and clavicle were found to be the most commonly fractured bones. Further prospective research into track regulations, protective equipment and course design may reduce the trauma burden in this athlete population.

The Prevalence of MRSA Nasal Carriage in Preoperative Pediatric Orthopaedic Patients.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) has been described as a risk factor for postsurgical infection. The purpose of this study is to determine the prevalence of MRSA in pediatric orthopaedic patients and whether being a MRSA carrier is a predictor of postoperative infection. Six hundred and ninety-nine consecutive pediatric patients who underwent MRSA nasal screening prior to surgery were studied. Postoperative cultures, total surgical site infections (SSIs), and epidemiological and surgical prophylaxis data were reviewed. Forty-four of 699 patients (6.29%) screened positive for MRSA. Nine of the 44 patients (20.5%) that screened positive for MRSA had a subsequent SSI compared to 10 of the 655 patients (1.52%) that screened negative (p < 0.05). All 9 patients with a SSI had myelomeningocele. The prevalence of MRSA was 6.30% and was predictive of postoperative infection. Children with myelomeningocele were at the highest risk for having a positive MRSA screening and developing SSI.

Complete remodelling of displaced fractures of the neck of the phalanx.

Fractures of the neck of the phalanx of the finger are uncommon, but problematic, injuries in children. Displaced fractures may heal with malunion leading to loss of movement or angular deformity. Remodelling of the phalangeal neck is reported to be minimal because of the distance of the fracture from the physis. We report three displaced fractures in two children who presented late. The fractures were treated conservatively and remodelled completely. Both patients regained full movement of the fingers.

Prevalence of positive preoperative pregnancy testing in teenagers scheduled for orthopedic surgery.

The pregnancy status of female teenagers presenting for orthopaedic surgery is often unknown. Anesthetics may have teratogenic or abortive effects. The authors report the results of a screening program for unrecognized pregnancy in 532 female teenagers presenting for orthopaedic surgery. Five patients with a positive urine human chorionic gonadotropin test were identified, for a prevalence of 1 positive result in 106 patients tested (0.9%). Surgery was cancelled in each case.

Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey.

SUMMARY: This study aimed to determine treatment preference of various femoral fracture patterns in children by pediatric orthopedists and whether it is practice dependent. In September 1998, members of the Pediatric Orthopedic Society of North America were surveyed to determine their current preferences in treating each of four middle one-third femoral fracture patterns in four age groups. Forty-four percent (286/656) of those surveyed responded. For each fracture pattern, operative treatment was increasingly preferred over nonoperative as patient age increased, and the preferred treatments within the operative and nonoperative categories changed significantly as patient age increased. Fourteen specific cases of femoral head avascular necrosis were noted after rigid reamed and unreamed rodding. There is a statistically significant trend by pediatric orthopedists to treat older children's femur fractures operatively and younger children's nonoperatively. The consensus treatment is age dependent. The numerous cases of avascular necrosis after rigid rodding are a concern.

Relationship between ligamentous laxity and the site of upper extremity fractures in children: extension supracondylar fracture versus distal forearm fracture.

Eighty children who had fallen on an outstretched hand and sustained either a displaced supracondylar fracture (group 1) or a displaced distal forearm fracture (group 2) were prospectively studied. Ligamentous laxity in these 80 patients was determined by four methods: (a) contralateral elbow hyperextension, (b) knee hyperextension, (c) the ability to touch the thumb to the ipsilateral forearm, and (d) the ability to extend the thumb past the ulnar border of the clenched fist. Elbow hyperextension averaged 10.5 degrees in group 1 and 4.4 degrees in group 2 (P < 0.0001). Knee hyperextension averaged 7.2 degrees in group 1 and 2.4 degrees in group 2 (P < 0.001). Twenty-one of 38 patients in group 1 (55%) compared with 8 of 42 patients in group 2 (19%) could touch the thumb to the ipsilateral forearm (P < 0.001). Twenty-seven of 38 patients in group 1 (71%) compared with 5 of 42 patients in group 2 (12%) could extend the thumb past the ulnar border of the clenched fist (P < 0.001). The authors conclude that a child who demonstrates ligamentous laxity is more likely to sustain an extension supracondylar humerus fracture than a distal forearm fracture when he or she falls on the outstretched hand to break the force of the fall.

The treatment of pediatric femur fractures with early 90-90 spica casting.

Twenty-three consecutive children younger than 6 years with a closed femoral shaft fracture stemming from low-energy trauma were treated with an early spica cast. With the patient under general anesthesia, a fiberglass cast was applied in sections. A short-leg cast was applied first, and then the patient was placed on the spica table. The hip and knee were flexed to 90 degrees, and traction was applied to the injured limb via the short-leg cast while the cast was completed. The popliteal fossa was well padded, and a valgus mold was placed at the fracture site. The average number of days in the spica cast was 42 (range, 18-57 days). Average shortening of the fracture at the time of cast removal was 1.0 cm (range, 0.1-2.1 cm). Final patient examinations were performed 18-24 months after the fracture. Overgrowth averaged 1.1 cm in the femur (range, 0.5-1.9 cm) and 0.4 cm (0-0.7 cm) in the tibia. Limb lengths in each patient were within 1 cm of the contralateral limb when measured by scanogram and by blocks. The success of early spica cast treatment in this series can be attributed to strict patient selection and meticulous cast application.

A comparison of three methods for measuring patella malalignment in children.

This study compared the Insall-Salvati (IS), Blackburne-Peel (BP), and Koshino-Sugimoto (KS) methods for measuring patellar malalignment in children. The IS and BP methods were inaccurate because the traditional landmarks for measurement were absent in the incompletely ossified pediatric knee. The KS method is based on the midpoint of the patella, the distal femoral physis, and the proximal tibial physis. The KS method applied to the extended knee was also inaccurate because of laxity in the patella ligament. However, the KS method applied to the flexed knee was the most accurate method for measuring patella malalignment in children.

Correlation of MRI and arthroscopic diagnosis of knee pathology in children and adolescents.

The accuracy of magnetic resonance imaging (MRI) in diagnosing knee pathology in the pediatric and adolescent population is not well established. The purpose of this study was to correlate the findings of MRI and knee arthroscopy in children and adolescents. One hundred and eight consecutive knee arthroscopies performed in patients ages 4-17 years between 1992 and 1996 were retrospectively reviewed. Fifty-three of these patients underwent preoperative MRI. Age-related comparisons were then made between MRIs and observed intraoperative meniscal and anterior cruciate ligament pathology. The pediatric group (ages 4-14 years) was demonstrated to have an appreciable decrease in sensitivity, specificity, positive predictive value, and accuracy for essentially all categories of pathologic changes. Conversely, negative predictive values for the pediatric group exceeded those of the adolescent group (ages 15-17 years) in each category. The ability of MRI to predict intraarticular knee pathology among adolescents is comparable to that in adults, whereas it is much less accurate in the pediatric population.

The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children.

We performed a prospective study of 20 patients with displaced extension supracondylar humerus fractures and evaluated the effect of elbow flexion, forearm supination, and forearm pronation on blood flow to the injured arm after closed reduction and Kirschner wire fixation. Ten patients had a Gartland type II fracture and 10 patients had a Gartland type III fracture. After closed reduction and percutaneous pinning, the radial pulse was examined with Doppler ultrasonography starting with the elbow in extension. The elbow was slowly flexed, and the angle of elbow flexion at which the radial pulse disappeared was determined. This angle of elbow flexion was measured with the forearm in both supination and pronation. Gartland type III fractures demonstrated less elbow flexion prior to radial pulse ablation compared to Gartland type II fractures when the forearm was placed in supination (p = 0.001) and in pronation (p = 0.005). Supination allowed > or = 5 degrees of elbow flexion prior to radial pulse ablation in six Gartland type II and four Gartland type III fractures. We concluded that after closed reduction and percutaneous Kirschner wire fixation of displaced extension supracondylar fractures, vascular safety is enhanced by extending the elbow and supinating the forearm. The ideal position of elbow immobilization depends on the amount of swelling and the presence of a radial pulse.

Newborn clavicle fractures.

A prospective screening program of 9106 newborns identified 43 infants with clavicle fractures for a prevalence of 1 fracture in every 213 live births (0.5%). The fractures were equally distributed by right and left side involvement, and male and female sex. All fractures occurred during vaginal deliveries. None were breech presentation. Risk factors for fracture included large birth-weight, shoulder dystocia, mechanically assisted delivery, and prolonged gestational age. One in 11 newborns with a clavicle fracture also had a brachial plexus palsy.

Surgical treatment of displaced medial epicondyle fractures in adolescent athletes.

Eight adolescent athletes (average age, 11 years; range, 9 to 15) underwent open reduction and internal fixation of acute, displaced medial epicondyle fractures. Fixation was achieved with a screw and washer. Four patients (50%) had associated elbow dislocations. Elbow motion in a brace was initiated 4 days after surgery. The brace allowed full flexion and extension but protected the elbow against valgus stress. Bracing was continued for 4 weeks. The average duration of followup was 10 months (range, 6 to 13). All fractures united, and full motion was achieved in seven patients. One patient lost 5 degrees of hyperextension compared with the opposite elbow. All eight elbows were stable to valgus stress and were pain-free. All patients returned to full sports activity.

Arthroscopically assisted treatment of acute septic knees in infants using the Micro-Joint Arthroscope.

Five infants with an acute hematogenous septic arthritis of the knee were treated with arthroscopically assisted drainage using the Micro-Joint Arthroscope (MJA; Linvatec, Largo, FL) combined with antibiotic therapy and early postoperative motion. The average patient age was 16 months (range, 4 to 24 months). No surgical or anesthetic complications occurred. All knees were clinically and radiologically normal at an average follow-up of 26 months.

Prospective evaluation of newborn soft-tissue hip "clicks" with ultrasound.

Fifty infants with soft-tissue hip "clicks" persisting after age 3 months were prospectively studied by using ultrasound. All children demonstrated a stable hip examination by Barlow and Ortolani maneuvers; however, a click was palpated with abduction and adduction of the hip. Static ultrasonography demonstrated an average alpha angle of 63 degrees in uninvolved hips and 62 degrees in the clicking hips. All hips had > 50% femoral-head coverage by the acetabulum. Dynamic ultrasound examination was normal in all cases. The soft-tissue clicks were not related to instability in this series of 50 infants.

Complications when using the cannulated 3.5 mm screw system.

Five patients with breakage of instrumentation when using the cannulated 3.5 mm screw system for fracture fixation are reported. Four 1.25 mm guide wires were sheared off by the cannulated drill and one 3.5 mm cannulated tap sleeve fractured. This article presents potential dangers when using the cannulated 3.5 mm screw system for general fracture care.

Postaxial type-B polydactyly. Prevalence and treatment.

A prospective screening program of 11,161 newborns identified twenty-one infants who had postaxial type-B polydactyly (a prevalence of one in 531 live births). Sixteen infants (76 per cent) had bilateral postaxial type-B polydactyly. Eighteen infants (86 per cent) had a family history of the anomaly. The racial prevalence was one in 143 live births of black infants and one in 1339 live births of white infants. The duplicated small fingers were treated in the newborn nursery with suture ligation at the base of the pedicle. One infant had a second procedure to remove a blackened digit that remained firmly attached one month after the initial treatment. No other complications occurred. Fifteen patients (twenty-eight fingers) were reexamined at an average age of twenty months (range, twelve to thirty-seven months). Twelve fingers (43 per cent) had a residual bump, with an average diameter of two millimeters (range, one to six millimeters). Despite the residual bumps, all of the parents were satisfied with the cosmetic result.

A 2-month-old infant with acute swelling of the extremities and mandible.

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopedic surgeon. The initial history, physical findings, and roentgenographic examinations are found on the first two pages. The clinical and roentgenographic diagnoses are presented on the following pages.

In-line skating fractures in children.

Seventy-eight fractures are reported in 61 children who fell while in-line skating. Distal radius or radius and ulna fractures as a result of falls on the outstretched hand occurred in > 75% of cases. Almost half of the patients were novices with < 4 weeks of experience on in-line skates. In fact, one in eight children sustained a fracture during the first attempt at the sport. Closed reductions were needed in 26 cases. Only two of 61 children were wearing any protective equipment at the time of the fracture.

Parent satisfaction comparing two bandage materials used during serial casting in infants.

Plaster of Paris was compared with semirigid fiberglass casting material during serial casting in 17 infants with clubfoot or rigid metatarsus adductus. Semirigid fiberglass was statistically superior in its durability, convenience, performance, and ease of removal. The average amount of time for home cast removal by the parents was 55 minutes for plaster of Paris and 21 minutes for semirigid fiberglass. Complications such as skin abrasions and cast slip-off were similar for both casting materials. Ninety-four percent of parents strongly preferred semirigid fiberglass rather than plaster of Paris for their child's serial casting.