Inadvertent Radial Head Inversion During Closed Reduction of a Pediatric Radial Neck Fracture.

Management of displaced pediatric radial neck fractures can be fraught with challenges. This unique case presents an 11-year-old female with a Salter-Harris type II radial neck fracture and how her radial head overturned 180° with the articular surface facing the radial shaft rather than the capitellum during closed manipulation under anesthesia. The malreduction subsequently required open reduction and highlights the importance of a careful stepwise approach to managing markedly displaced radial neck fractures. After closed reduction, meticulous assessment of intraoperative imaging when determining proper alignment is of the utmost importance as a result of the transverse nature of Salter-Harris type I and II fractures. LEVEL OF EVIDENCE:: Level IV.

The lateral capitellohumeral angle in normal children: mean, variation, and reliability in comparison to Baumann's angle.

BACKGROUND: Angular deformity is the most common complication of supracondylar humerus fracture. Baumann's angle (BA) is an established radiographic measure of coronal plane deformity after this injury. Numerous radiographic methods have been used to assess sagittal plane deformity, however, the mean, variability, and reliability of these measures has not been established. The purpose of this study was to determine the mean, SD, and intraobserver/interobserver reliability of the lateral capitellohumeral angle (LCHA) in children without evidence of fracture and compare them with those of BA. METHODS: Seventy-one sets of anteroposterior and lateral elbow radiographs were selected and stratified into 6-year age categories with equal number of males and females in each category. Five physicians performed 3 separate measurements of LCHA and BA on each film set. Statistical calculations were performed to determine mean, SD, measurement reliability, and differences between patients groups. RESULTS: The mean LCHA ±1 SD and BA ± 1 SD measurements were 50.8 ± 6 degrees and 71.5 ± 6.2 degrees, respectively, and did not vary significantly by age, side, or sex (P>0.05). The LCHA showed good intraobserver (correlation coefficient 0.67) and fair interobserver (0.37) reliability, whereas BA showed excellent intraobserver (0.86) and interobserver (0.80) reliability. The expected SD for repeated measurement of a radiograph by a single observer was 2.6 degrees for BA and 5.2 degrees for LCHA. CONCLUSIONS: The LCHA is a simple measurement to perform using digital tools. In normal elbows, the mean angle is 51 ± 6 degrees and does not vary by age, side, or sex. LCHA variability in normal elbow radiographs is similar to BA. Its reliability is inferior to BA, but improves with age. Sagittal angulation abnormality of at least 12 degrees (<39 or >63 degrees) is necessary to be confident that the change is not because of measurement error alone. Further research is needed to better define the relationship of sagittal plane angular deformity to clinical outcome. LEVEL OF EVIDENCE: Diagnostic study with poor reference standard, Level IV.

Valgus slipped capital femoral epiphysis: prevalence, presentation, and treatment options.

BACKGROUND: Valgus slipped capital femoral epiphysis (SCFE), defined as posterolateral slippage of the proximal femoral epiphysis on the metaphysis, is an uncommon occurrence. The purpose of this study was to review our institution's experience with valgus SCFE to better describe its prevalence, clinical presentation, and treatment. METHODS: Radiographs of patients undergoing treatment of SCFE between 1996 and 2008 were reviewed. Valgus SCFE was identified by increased prominence of the lateral femoral epiphysis relative to the lateral femoral neck and an increased anteroposterior physis shaft angle. We identified 12 patients (16 hips) with valgus SCFE and compared them with 123 cases identified as classic posteromedial SCFE. RESULTS: The prevalence of valgus SCFE at our institution was 4.7% (12 of 258 patients). Significant differences between patients with valgus SCFE and those with classic SCFE were found for age at presentation (mean 1.1 y younger, P=0.033), sex (58% female vs. 28% male, P=0.044), and classification as atypical SCFE (42% vs. 3%, P<0.001), respectively. Four patients in the valgus group had pituitary and growth hormone dysfunction, and 1 was diagnosed with Stickler syndrome. Hips of valgus patients had a significantly higher mean femoral neck shaft angle (154.3 degrees) as compared with classic SCFE patients (140.5 degrees) (P<0.001). Difficulty placing hardware for in situ fixation was noted in 5 of 11 valgus cases, with 1 case complicated by articular surface penetration and chondrolysis. CONCLUSIONS: Valgus displacement often presents with a relatively normal appearance on anteroposterior radiographs. Valgus SCFE may be associated with obesity, coxa valga, hypopituitarism, and Stickler syndrome. Posterolateral displacement of the femoral epiphysis makes in situ fixation of valgus SCFE more difficult, due to the necessity of a more medial starting point. LEVEL OF EVIDENCE: Case series, Level IV.

Osteomyelitis in the diabetic foot: diagnosis and management.

Neuropathic ulcerations and altered immune function place the diabetic patient at increased risk for polymicrobial osteomyelitis of the foot and ankle. The optimal method for evaluation and management of this difficult condition is controversial, and further studies are needed. Infected ulcers with exposed or palpable bone can be assumed to have underlying osteomyelitis. Although plain film should be ordered in each case, MRI is most often used for evaluation and surgical planning. Difficult cases, such as those associated with Charcot osteoarthropathy, may require labeled leukocyte scanning or bone biopsy to arrive at the diagnosis. A multidisciplinary team approach is best, allowing optimal treatment of all associated conditions that commonly affect patients with diabetes mellitus. Vascular evaluation and intervention are critical in the presence of vascular insufficiency or ischemia. Empiric, usually broad-spectrum antibiotics and meticulous local wound care may achieve remission of mild to moderately severe infections and should be included in all treatment regimens. Severe, infections, ischemia, or sepsis requires an aggressive surgical approach. Bone resection, correction of deformity, or amputation often are necessary and should be done with the goal of salvaging a functional foot.