Cast-saw burns: comparison of technique versus material versus saws.

Inadvertent cast-saw burns are attributable to inadequately padded casts, improper technique, or uncooperative patients. Cast-saw blade temperatures recorded while splitting plaster and fiberglass casts are elevated to a degree that would increase the risk of a second- or third-degree burn. Using standardized plaster and fiberglass cast models, this study attempted to determine whether the elevated temperature was a product of the saw, blade design, blade material, technique of cast removal, or casting materials. The results demonstrated that cast-saw blades manufactured with stainless steel are poorly suited for a device that uses friction to separate a cast. Modifications to the technique and varying the cast-saw models did not reduce the blade temperature consistently to <120-130 degrees F during normal operations.

Improved percutaneous slipped capital femoral epiphysis treatment: continuous biplanar fluoroscopy and proper guide wire selection.

In 1990, a report was published outlining a technique of percutaneous fixation of slipped capital femoral epiphyses dramatically diminishing the morbidity associated with the open technique. Technical difficulties are still encountered with the morbidly obese child and the percutaneous technique. Two fluoroscopic units used continuously during the technique facilitate placement of the guide wire in a more acceptable anatomic location. Guide wire stiffness was also measured and used in preoperative planning. Ten hips were treated with this technique, and a prospective analysis of the surgical time and fluoroscopy time was done. Using the new technique, we found a significant reduction in surgical and fluoroscopic times.

Treatment of unicameral bone cyst with demineralized bone matrix.

Eleven patients with active unicameral bone cysts were treated primarily with placement of demineralized bone matrix in the cyst by using a two-needle technique and a custom large-bore needle. Cyst healing was rated according to the Neer classification, and the average time of healing was 4.5 months. The demineralized bone matrix demonstrated an ability to obliterate the cyst in nine of 11 patients by using a single injection within 4-5 months, and at 2 years' follow-up, no cysts were deemed active or recurrent.

Pediatric vertebral osteomyelitis: diagnosis using computed tomography.

The diagnosis of pediatric vertebral osteomyelitis has been enhanced through the use of computed tomography scan and magnetic resonance imaging. A retrospective analysis of seven patients with vertebral osteomyelitis was done to determine the studies used in medical management decisions and the outcome of these studies. Computed tomography scans were valuable in predicting if a patient would respond to medical management. The presence of a phlegmon on the computer-assisted tomography scan uniformly resulted in a failure of medical management or an indication for primary surgical management.

Improved treatment of femoral shaft fractures in children utilizing the pontoon spica cast: a long-term follow-up.

This prospective study looked at 91 pediatric femur fractures. Patients were randomized into two groups: (a) A traditional group treated with 3 weeks in traction followed by spica; and (b) a pontoon spica group in which patients were treated first with only a few days in traction and then with a 90-90 pins-in-plastic spica. The pontoon spica provides excellent short- and long-term results. These include (a) providing substantial cost savings; (b) causing much less inconvenience to the family and child; (c) reducing the number of inpatient days, thereby freeing hospital beds; (d) permitting early motion; (e) reducing the number of short-term complications; and (f) preventing excessive shortening while controlling rotation.

Evaluation of acute gait abnormalities in preschool children.

The charts of 60 consecutive children aged less than 5 years hospitalized for evaluation of a new onset limp or refusal to bear weight were reviewed. Only 1 of 22 patients with a normal complete blood count (CBC), erythrocyte sedimentation rate (ESR), and temperature had an infection. Of the 14 patients with a diagnosis of infection, only one had a normal CBC, ESR, and temperature. Radiographs were diagnostic in only four cases, whereas aspiration identified nine of 13 infections. Thirty-five bone scans were performed; 18 led to a definitive diagnosis including synovitis osteomyelitis, Perthes disease, juvenile rheumatoid arthritis, (JRA), fracture, soft tissue infection, and discitis.

Transient osteoporosis.

Six hips in four patients with hip pain, limited range of motion, no antecedent trauma, and normal laboratory studies demonstrated roentgenographic evidence of periarticular osteoporosis. The subchondral cortex was attenuated. There was little or no cartilage loss. The preliminary diagnosis was transient osteoporosis (migratory osteolysis, regional osteoporosis). This problem is most frequently seen in the hip joint in two population groups: men near 40 and women in the third trimester of pregnancy. Other joints may be involved and the process may regress in one joint but recur in another. Diagnosis is based on typical clinical and roentgenographic observations including an aspiration of sterile joint fluid. Radioisotope scanning may be helpful. Bone or synovial biopsy sampling is not necessary. Proper management requires accurate diagnosis and conservative treatment of a cooperative patient. Pain may persist for six months or longer. Treatment consists of analgesics, protection against stress fractures, and physical therapy for prevention of contractures.

Closed Zickel nailing.

A closed technique for Zickel nail insertion decreases morbidity, blood loss, and operative time. The Zickel intramedullary nail was originally developed as an open fixation device for fractures of the proximal third of the femur and subtrochanteric area. The open technique requires a lengthy incision, moderate blood loss, and time for insertion. For pathologic or impending pathologic fractures in sick patients, such a major operation is undesirable. The closed technique has been used successfully in five impending pathologic, three pathologic, and two traumatic subtrochanteric fractures. For these ten patients, the average operating time was one hour and 28 minutes with an average blood loss of 400 ml, a reduction of 40 minutes and 460 ml, respectively, over other available data. Time to ambulation and length of hospital stay are comparable to fractures treated openly. The closed technique is ideal for impending pathologic fractures, but may also be applicable to any pathologic or traumatic fractures that do not require an open procedure for alignment or supplementary fixation.

Preoperative skeletal traction in Legg-Perthes disease.

In four of 11 patients with Legg-Perthes disease for which a varus femoral osteotomy was planned, routine split Russell traction failed to produce complete preoperative containment. Preoperative skeletal traction was used to distract the joint, displace the extruded lateral physis below the acetabular margin, and then reintroduce the femoral head into the acetabulum with progressive abduction. The femoral heads were rated postoperatively as good (two cases), fair (two cases), and poor (one case). Preoperative skeletal traction is an adjunctive treatment method for patients with "hinge abduction" in whom a varus femoral osteotomy is indicated.

Syndactyly reconstruction by a modified Cronin method.

In 11 patients (1 to 28 years of age) having elective surgical release of congenital or burn syndactyly in 1982-1983, we used the modified Cronin method of web reconstruction with double opposing, inverted V-shaped flaps and full-thickness skin grafts. Postoperatively, the hands were splinted for three weeks, at which time we changed the dressing, with the patient under anesthesia. The hands were then immobilized for an additional three weeks. At the last clinic visit (13 to 20 months postoperatively) the hands were evaluated for adequacy of web space reconstruction, cosmesis, and postoperative complications. There was one partial loss of a full-thickness skin graft, which required regrafting when the patient prematurely removed his dressing. One proximal interphalangeal joint contracture required splinting. The web space reconstruction was judged adequate in all hands, and all patients and parents were pleased with the cosmetic results. This method of reconstruction gives good results and its web space reconstruction is technically easier than other methods.