Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures.

INTRODUCTION: The majority of proximal humeral fractures in the skeletally immature are treated non-operatively. Operative indications vary but are largely based on degree of displacement. Non-union is rare. Non-operatively treated fractures are typically monitored radiographically to assess healing. HYPOTHESIS: We hypothesize that the decision to treat fractures operatively is made at the time of first imaging and that follow-up X-rays do not lead to a change in management. MATERIAL AND METHODS: We retrospectively reviewed the records of 239 patients treated for proximal humerus fractures over a 5-year period. There were 225 who were treated non-operatively. Records were reviewed for the number of clinic visits and radiographs, as well as any change to operative management based on follow-up X-rays. RESULTS: The primary outcome of the study was the proportion of proximal humerus fractures, initially treated non-operatively, for which displacement or angulation on follow-up radiographs led to a change to operative treatment. Secondary outcomes were the number of follow-up radiographs obtained after the initial diagnosis and initiation of non-operative treatment. Of the 225 patients that were initially managed non-operatively, only 1 patient required subsequent surgical management. This patient underwent a proximal humerus epiphysiodesis 365 days from injury after development of a partial growth arrest. The mean number of fracture clinic visits for patients managed non-operatively was 2.67 (±1.24). The mean number of radiology department visits and radiographs obtained was 3.57 (±1.44) and 8.36 (±3.89) respectively. No clinical or radiographic non-unions were identified in these patients. No patients suffered a refracture during the review period. DISCUSSION: This study shows that of the 239 uncomplicated pediatric proximal humerus fractures treated at our hospital over a 5-year period, only 1 had a change in treatment plan, from non-operative to operative, based on follow-up radiographs. These data suggest that non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention. Moreover, they suggest that there is little utility to the routine use of postoperative radiographs in follow-up of these patients. STUDY DESIGN: Retrospective case series. LEVEL OF EVIDENCE: IV.

Pedestrian injuries in school-attending children: a comparison of injury data sources in a low-income setting.

OBJECTIVE: To estimate and compare the rate of pedestrian injuries in primary school-attending children of urban Uganda using different data sources. DESIGN: Data collection from a hospital-based trauma registry, police data, teacher reports, and a cross-sectional community-based survey. SETTING: Kawempe, the largest urban district in the capital Kampala, Uganda. Patients or SUBJECTS: Primary school-attending children aged 4-12 from 39 randomly selected schools were included in the trauma registry, police data, and teacher reports. 1828 households randomly selected from the 39 schools were interviewed for the community survey. MAIN OUTCOME MEASURE: A pedestrian injury. For the trauma registry-defined as a pedestrian injury resulting in a visit to the hospital. For the police data-defined as a pedestrian injury reported to the police. For the teacher reports and survey-defined as a pedestrian injury resulting in at least a day off school. RESULTS: The estimated pedestrian injury rates per 100 000 person-years were 54.0 (95% CI 25.3 to 117.4), <53.97 (95% CI 23.8 to 125.9), 1878.8 (95% CI 1513.1 to 2322.4), and 764.0 (95% CI 523.3 to 1117.2) from the trauma registry, police data, teacher reports, and community survey, respectively. CONCLUSIONS: Pedestrian injury rates differed significantly between different data sources. Users must be aware of the different target populations, definitions, and limitations of the data sources before direct comparisons are made. Injury reports by volunteer teachers may be a feasible source of injury data in other low/middle-income countries.

Once bitten, twice shy? Medically-attended injuries can sensitise parents to children's risk of injuries on playgrounds.

OBJECTIVE: To compare risk perceptions of parents whose child sustained a medically attended playground injury (cases) with those of parents whose child had not (controls) to address two questions. Does having a child experience a medically attended injury: (1) sensitise parents to children's injury vulnerability and severity; (2) influence parents' appraisal of the injury mechanism (child's behaviour), attributions for injuries or beliefs about strategies for prevention? METHOD: Each case-control parent dyad was assigned to one of two conditions: (1) being presented with 10 common injury-risk playground behaviours specific to the equipment on which their child had been hurt, and asked to appraise injury vulnerability and severity; or (2) being presented with scenarios about playground injuries that varied in severity but were all based on the same child behaviour, and asked questions about this behaviour, attributions for injury and strategies for prevention. RESULTS: The results support the occurrence of a sensitisation process. Compared with control parents, case parents showed higher ratings of injury severity and children's vulnerability to injury, made fewer attributions for injuries to bad luck, and endorsed a greater diversity of prevention strategies, including parent (closer supervision), child (teaching rules about safe play on playgrounds) and environmental (modifications to playgrounds). CONCLUSIONS: A child's medically attended injury can create a "teachable moment" for the parent. Linking injury-prevention programming to this teachable moment may increase the likelihood of evoking changes in parental supervisory behaviour and their setting of rules limiting their child's risk behaviours to reduce the occurrence of childhood injury.

Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children.

The authors assessed whether a period of 3 weeks, rather than the commonly used 6 weeks, of smooth Kirschner wire fixation and cast immobilization of the elbow was sufficient to achieve union of displaced fractures of the lateral humeral condyle treated by open reduction. The authors found only one nonunion in a case series of 104 children treated with 3 weeks of fixation. Infections occurred in two children (2%). Late review of 63 children (61%) showed abnormalities of elbow shape in 28 (44%) and wide surgical scars in 43 (68%). The abnormalities of elbow shape were mainly due to overgrowth of the lateral humeral condyle, to the formation of excessive amounts of bone over the outer surface of the condyle, or both. The authors' findings indicate that a period of 3 weeks of smooth Kirschner wire fixation and elbow immobilization is sufficient to achieve healing in most displaced fractures of the lateral humeral condyle treated by open reduction. The findings also indicate that new strategies are needed to reduce the occurrence of overgrowth of the lateral condyle, excessive formation of bone over the condyle, and wide scars.

A social problem index for Canada.

OBJECTIVE: To construct an index that represents the general level of social problems among Canadian provinces and territories. METHOD: Factor weights were used to combine provincial and territorial rates for homicide, attempted murder, assault, sexual assault, robbery, divorce, suicide, and alcoholism into a single Social Problem Index. RESULTS: The resulting index demonstrated strong positive intercorrelations among its factors across provinces. That is, provinces that showed high rates on one factor tended to show high rates on the others as well. The validity of the Social Problem Index is demonstrated by its positive correlation with an independent measure of the likelihood of having experienced personal trauma. CONCLUSIONS: The robust nature and apparent validity of the Social Problem Index suggest that it can be well used for needs assessments and theoretical studies and as a feedback mechanism to national, provincial, and community leaders on the social problem status of their particular jurisdictions.

Limited dorsiflexion predisposes to injuries of the ankle in children.

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7 degrees with the knee extended and 11.2 degrees with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8 degrees with the knee extended and 21.5 degrees with the knee flexed (p < 0.001, Student's t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility.

Cervical spondylolysis in children: is it posttraumatic?

Cervical spondylolysis is a rare defect of unknown etiology. Five cases of cervical spondylolysis as well as two cases of fractures of the pedicles of C2 in infants are presented. Comparison of the cases suggests that a fracture at birth or in infancy may be the cause of some cases of cervical spondylolysis.

Children, automobile restraints and injuries.

Injuries are the most common cause of death for Canadians aged one to 18 years, and 50% of injury deaths in this age group involve an automobile. Evidence suggests that 71% reduction in deaths and a 67% reduction in injuries can be achieved when child safety seats are used properly. This article reviews the recommended restraints for children by weight group and describes the proper position for children. Detailed case examples of car crashes are described to illustrate the dangers of incorrectly used or no restraint.

Reduction in osteomyelitis and septic arthritis related to Haemophilus influenzae type B vaccination.

This retrospective cohort study compares organisms responsible for septic arthritis and osteomyelitis before and after Haemophilus influenzae type b vaccination. Before vaccination, Haemophilus influenzae type b was responsible for 5% of culture positive osteomyelitis and 41% of culture positive septic arthritis. Since the administration of the conjugated vaccine PRP-T began in 1992, no case of osteomyelitis or septic arthritis has been caused by Haemophilus influenzae type b (p < 0.005, t test). Vaccination has succeeded in eliminating Haemophilus influenzae type b as an infective agent in hematogenous septic arthritis and osteomyelitis. Current empirical antibiotic therapy for hematogenous septic arthritis and osteomyelitis need only cover gram-positive agents in vaccinated infants and children of all age groups.

Low molecular weight heparin decreases proximal and distal deep venous thrombosis following total knee arthroplasty. A meta-analysis of randomized trials.

OBJECTIVES: To assess the efficacy and safety of low molecular weight heparin (LMWH) as deep venous thrombosis (DVT) prophylaxis following total knee arthroplasty. DATA SOURCES: Medline 1986 to June 1997, Embase, and manufacturers were used to identify randomized controlled trials. REVIEW METHODS: Trials included were randomized studies of LMWH with routine radiological screening for DVT. Placebo or active controls were included. Two reviewers independently screened trials for inclusion, and assessed their quality. Pooled relative risk estimates of DVT and proximal DVT rates were calculated using a DerSimonian and Laird random effects model. Sensitivity of the results to the type of control used and the quality of the trial was assessed. RESULTS: The relative risk of DVT for a patient given LMWH is 0.73 (95% CI 0.66 to 0.80) when compared with patients treated with adjusted dose heparin or warfarin controls. The relative risk for proximal DVT is 0.58 (95% CI 0.38 to 0.90). The relative risk of pulmonary emboli in the LMWH group was 0.55 (95% C.I. 0.20 to 1.57). No excess of bleeding was recorded in the LMWH group. CONCLUSIONS: Low molecular weight heparin is more efficacious than either adjusted dose heparin or adjusted dose warfarin, when used to prevent DVT and proximal DVT following total knee arthroplasty.