Referral patterns to a pediatric orthopedic clinic: pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians.

In 2004, Reeder and in 2012, Schwend reported that inappropriate nonsurgical referrals to pediatric orthopedic clinics create a misuse of resources. Additional authors have called for re-emphasis and additional training in musculoskeletal medicine for primary care physicians (PCP) to improve the confidence, knowledge and performance when managing musculoskeletal conditions. The current study compares the diagnoses referred to a pediatric orthopedic clinic with diagnoses recommended for referral by the American Academy of Pediatrics (AAP) guidelines to determine if any improvement in the quality of referrals has occurred since Reeder and Schwend's article. A chart review of new referrals to a pediatric orthopedic clinic during a 3-month-period was performed. Data were collected on age, sex, referring diagnosis, referral source, final diagnosis and treatment. In total 230 new consults were evaluated. The referral source was a PCP in 169 (73.5%) cases, 30 (13%) self-referrals by a parent, 19 (8.3%) from another orthopedic surgeon, 9 (3.9%) from a neurologist and 3 (1.3%) from another specialist. Fifty percent of referrals met the criteria outlined in the AAP guidelines for referral to a pediatric orthopedic specialist and 48% were classified as primary care musculoskeletal conditions. During the 15 years since the publication of Reeder's study and despite a limited re-emphasis on musculoskeletal education, the percent of inappropriate referrals to a pediatric orthopedic clinic remains unchanged at 50%. We support an expanded musculoskeletal educational effort aimed at the medical, resident and pediatrician level, online decision-making aids, and implementation of a standardized referral form with the specific criteria of the AAP included.

Peroneal Artery-based Propeller Flap to Cover the Medial Distal Tibia in the Absence of the Posterior Tibial Artery.

A healthy 28-year-old woman restrained driver presented to the trauma unit post-MVC with significant vehicular intrusion. Examination demonstrated a 15-cm transverse wound over the medial malleolus and anterior ankle with exposed muscle, tendon, and bone without gross contamination. Her physical examination was otherwise unremarkable. Distal to the wound, there was no Doppler signal in either dorsalis pedis or posterior tibial arteries and the foot appeared cold with delayed cap refill. She was taken to the operating room urgently for debridement and irrigation, open reduction internal fixation of both distal tibia and fibular fractures, and supplemental external fixation application. The foot regained a normal color and capillary refill upon reduction, and biphasic Doppler signals returned.

Fixation of type 2a supracondylar humerus fractures in children with a single pin.

BACKGROUND: The AAOS guidelines suggest operative fixation of all type 2 supracondylar humerus fractures. Not all type 2 fractures are the same. Wilkins type 2a fractures have intrinsic stability. The purpose of this paper is to report closed reduction and single-pin fixations for Wilkins 2a fractures. METHODS: Fifteen consecutive type 2a fractures treated with single-pin fixation were prospectively evaluated. Procedure notes, age, sex, side involved, duration of immobilization, and complications were recorded. Radiographs were measured for the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded. RESULTS: The average age of patients was 5 years (age range, 1 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases and a 2 mm K-wire was used in 13 cases. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum. Following pinning, the elbow was immobilized in a long-arm cast in pronation with elbow at 75 degrees of flexion. The cast and pin were removed at an average of 27 days (range, 25 to 31 d). One patient was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no complications. CONCLUSIONS: Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization of type 2a fractures in children. LEVEL OF EVIDENCE: Level III.