Elhanan Bar-On

Anxiety reaction in children during removal of their plaster cast with a saw

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy.

Early Disaster Response in Haiti: The Israeli Field Hospital Experience

The earthquake that struck Haiti in January 2010 caused an estimated 230,000 deaths and injured approximately 250,000 people. The Israel Defense Forces Medical Corps Field Hospital was fully operational on site only 89 hours after the earthquake struck and was capable of providing sophisticated medical care. During the 10 days the hospital was operational, its staff treated 1111 patients, hospitalized 737 patients, and performed 244 operations on 203 patients. The field hospital also served as a referral center for medical teams from other countries that were deployed in the surrounding areas. The key factor that enabled rapid response during the early phase of the disaster from a distance of 6000 miles was a well-prepared and trained medical unit maintained on continuous alert. The prompt deployment of advanced-capability field hospitals is essential in disaster relief, especially in countries with minimal medical infrastructure. The changing medical requirements of people in an earthquake zone dictate that field hospitals be designed to operate with maximum flexibility and versatility regarding triage, staff positioning, treatment priorities, and hospitalization policies. Early coordination with local administrative bodies is indispensable.

Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study.

Background We evaluated the effect of adding dexamethasone to antibiotic therapy in the clinical course of septic arthritis in children. Methods A randomized double-blind placebo-controlled trial was performed. The study group included 49 children with septicarthritis. In addition to antibiotic therapy given, patients were randomly assigned to receive intravenous dexamethasone 0.15 mg/kg every 6 hours for 4 days or placebo. The groups were compared for clinical and laboratory parameters, length of hospital stay, and late sequelae. Results Mean age was 33±42 months (range: 6 to 161 mo). There was no significant difference between the dexamethasone and placebo groups in age, duration of symptoms, joint affected, or levels of acute phase reactants. Bacteria were isolated from joint fluid in 17 patients (35%) and from blood in 4 patients. Compared with the placebo group, patients treated with dexamethasone had a significantly shorter duration of fever (P=0.021; mean first day without fever 1.68 vs 2.83) and local inflammatory signs (P=0.021; mean first day without pain 7.18 vs 10.76), lower levels of acute phase reactants (P=0.003; mean last day of erythrocyte sedimentation rate>25 mm/h 3.76 vs 8.40), shorter duration of parenteral antibiotic treatment (P=0.007; mean of 9.91 d vs 12.60 d), and shorter hospital stay. No side effects of treatment were recorded in either group. Conclusions A 4-day course of dexamethasone given at the start of antibiotic treatment in children with septic arthritis, is safe, and leads to a significantly more rapid clinical improvement, shortening duration of hospitalization compared with those treated with antibiotics alone. Level of Evidence I.

Monitoring of the sciatic nerve during hamstring lengthening by evoked EMG

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG). Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90 degrees, 60 degrees and 30 degrees, and at the end of lengthening with the hip and knee extended. In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60 degrees was 34% (10 to 77), and to 30 degrees, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level. Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury.

Orthopaedic manifestations of familial dysautonomia. A review of one hundred and thirty-six patients.

Background: Familial dysautonomia is a hereditary multisystemic disease primarily affecting people of Ashkenazi Jewish descent. Musculoskeletal problems are related to gait disorders, spinal deformities, foot deformities, fractures, and arthropathies.Methods: The charts and radiographs of 136 patients who ranged in age from three months to forty-six years (mean, sixteen years) were reviewed. Sixty-four patients were available for follow-up examination.Results: Spinal deformity was the most common orthopaedic problem and was diagnosed in seventy-eight patients starting at the age of four years, with a prevalence of 86 percent (forty-eight of fifty-six) by the age of fifteen years. Forty-one (53 percent) of the seventy-eight patients had scoliosis only, thirty-four (44 percent) had kyphoscoliosis, and three (4 percent) had kyphosis only. Bracing was accompanied by emotional, pulmonary, and skin problems, leading to a high rate of noncompliance and progression of the curve.Twenty-four patients had an operation at a mean age of thirteen years (range, five to eighteen years): twenty patients had posterior spinal arthrodesis, and four had combined anterior and posterior arthrodesis. Fifteen patients had a total of nineteen complications, of which seven were systemic and twelve were related to the spinal fixation. Eight patients had revision surgery. At the time of the surgery, scoliosis was corrected from a mean of 55 degrees to a mean of 35 degrees and kyphosis was corrected from a mean of 69 degrees to a mean of 61 degrees.After a mean duration of follow-up of sixty-five months, scoliosis measured 49 degrees (range, 18 to 62 degrees) and kyphosis measured 67 degrees (range, 30 to 115 degrees). Postoperative progression of the deformity was caused by failure of the instrumentation or progression in unfused segments. Walking was delayed in 72 percent (ninety-four) of the 130 patients who were of walking age. All sixty-four of the patients who were examined had an ataxic gait. Foot deformities were found in sixteen patients, six of whom were treated surgically. Two patients had Charcot joints. Fifty-five patients sustained at least one fracture before skeletal maturity, with a mean of 1.5 fractures per patient. All but one of the fractures was treated nonoperatively, and fracture-healing was often accompanied by profuse callus formation.Conclusions: Spinal deformity is common in patients with familial dysautonomia. Bracing is of questionable benefit, and surgical intervention should be considered once curve progression is well documented. Arthrodesis should be extended as far proximally as possible to prevent junctional kyphosis. Swelling and warmth in a limb should raise suspicion of an undiagnosed fracture.

Immobilisation of forearm fractures in children: EXTENDED VERSUS FLEXED ELBOW

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.

Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic-impregnated cement rods.

Background Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. Methods Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Childrens Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. Results Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. Conclusions The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. Level of Evidence Therapeutic study, clinical case series: level IV.

Coping with the challenges of early disaster response: 24 years of field hospital experience after earthquakes.

OBJECTIVE To propose strategies and recommendations for future planning and deployment of field hospitals after earthquakes by comparing the experience of 4 field hospitals deployed by The Israel Defense Forces (IDF) Medical Corps in Armenia, Turkey, India and Haiti. METHODS Quantitative data regarding the earthquakes were collected from published sources; data regarding hospital activity were collected from IDF records; and qualitative information was obtained from structured interviews with key figures involved in the missions. RESULTS The hospitals started operating between 89 and 262 hours after the earthquakes. Their sizes ranged from 25 to 72 beds, and their personnel numbered between 34 and 100. The number of patients treated varied from 1111 to 2400. The proportion of earthquake-related diagnoses ranged from 28% to 67% (P < .001), with hospitalization rates between 3% and 66% (P < .001) and surgical rates from 1% to 24% (P < .001). CONCLUSIONS In spite of characteristic scenarios and injury patterns after earthquakes, patient caseload and treatment requirements varied widely. The variables affecting the patient profile most significantly were time until deployment, total number of injured, availability of adjacent medical facilities, and possibility of evacuation from the disaster area. When deploying a field hospital in the early phase after an earthquake, a wide variability in patient caseload should be anticipated. Customization is difficult due to the paucity of information. Therefore, early deployment necessitates full logistic self-sufficiency and operational versatility. Also, collaboration with local and international medical teams can greatly enhance treatment capabilities.

Pediatric orthopedic injuries following an earthquake: Experience in an acute-phase field hospital

BACKGROUND Following the 2010 earthquake in Haiti, the Israel Defense Forces Medical Corps deployed a field hospital in Port au Prince. The purpose of this study was to characterize the injuries sustained by the pediatric population treated in the hospital and examine the implications for planning deployment in future similar disasters. METHODS Medical records of children treated in the hospital were reviewed and compared with medical records of the adult population. RESULTS A total of 1,111 patients were treated in the hospital. Thirty-seven percent were aged 0 to 18 years. Earthquake-related injuries were the cause of admission in 47% of children and 66% of adults. Forty-seven percent of children with traumatic injuries sustained fractures. Seventy-two percent were in the lower limbs, 19% were in the upper limbs, and 9% were in the axial skeleton, with the femur being the most common long bone fractured compared with the tibia in adults. There were four functional operating theaters, and treatment guidelines were adjusted to the rapidly changing situation. Soft tissue injuries were treated by aggressive debridement. Fractures were stabilized by external fixation or casting. Amputation was performed only for nonviable limbs or life-threatening sepsis. Children were more likely than adults to undergo surgery (44% vs. 29% of trauma patients). To maximize hospital surge capacity, minor procedures were performed in the wards under sedation, and patients were discharged after an average of 1.4 days, with subsequent follow-up in the clinic. CONCLUSION Children constitute a high percentage of patients in a developing country. The epidemiology of pediatric injuries following an earthquake differs significantly from that encountered in everyday practice and compared with that in adults. Children sustain a significantly higher percentage of femoral fractures and are more likely to require surgery. The shift to nontraumatic reasons for admission occurred earlier in the pediatric population than in adults. Organizations providing post-earthquake relief are usually geared toward adult populations and will require supplementation of both manpower and equipment specifically suited for treatment of pediatric patients. Early deployment teams should be adequately staffed with adult and pediatric orthopedists. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Dexamethasone Therapy for Septic Arthritis in Children

BACKGROUND AND OBJECTIVE: Prospective studies of children with septic arthritis report that adding dexamethasone to antibiotic therapy contributes significantly to clinical and laboratory improvement. This study sought to evaluate the effect of this regimen outside of a randomized controlled trial. METHODS: The sample consisted of children with septic arthritis hospitalized at a tertiary pediatric medical center in 2008 to 2013. Disease course and outcome were compared between children treated with antibiotics alone or with adjuvant dexamethasone, according to the admitting department policy. RESULTS: The cohort included 116 patients, 90 treated with antibiotics alone and 26 treated with antibiotics+dexamethasone. The groups were similar for age, symptom duration before hospitalization, body temperature, acute-phase reactant levels, and rate of positive fluid cultures (21.6% total). Compared with monotherapy, antibiotics+dexamethasone treatment was associated with a shorter duration of fever (mean 2.3 vs 3.9 days, P = .002), more rapid clinical improvement (mean 6.3 vs 10.0 days to no pain/limitation, P < .001), more rapid decrease in C-reactive protein level to <1 mg/dL (mean 5.3 vs 8.4 days, P = .002), shorter duration of parenteral antibiotic treatment (mean 7.1 vs 11.4 days, P < .001), and shorter hospital stay (mean 8.0 vs 10.7 days, P = .004). Recurrent symptoms of fever and joint pain occurred in 4 patients in the antibiotics+dexamethasone group after completion of the steroid course. CONCLUSIONS: Children with septic arthritis treated early with a short course of adjuvant dexamethasone show earlier improvement in clinical and laboratory parameters than children treated with antibiotics alone.