Joshua M. Abzug

Management of Supracondylar Humerus Fractures in Children: Current Concepts

&NA; Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. Type I fractures are managed nonsurgically, but most displaced injuries (types II, III, and IV) require surgical intervention. Closed reduction and percutaneous pinning remains the mainstay of surgical management. Numerous studies have reported recent alterations in important aspects of managing these fractures. Currently, many surgeons wait until 12 to 18 hours after injury to perform surgery provided the childs neurovascular and soft‐tissue statuses permit. Increasingly, type II fractures are managed surgically; cast management is reserved for fractures with extension displacement only. Two to three lateral pins are adequate for stabilizing most fractures. Evolving management concepts include those regarding pin placement, the problems of a pulseless hand, compartment syndrome, and posterolateral rotatory instability.

Evaluation and Management of Brachial Plexus Birth Palsy

Brachial plexus birth palsy can result in permanent lifelong deficits and unfortunately continues to be relatively common despite advancements in obstetric care. The diagnosis can be made shortly after birth by physical examination, noting a lack of movement in the affected upper extremity. Treatment begins with passive range-of-motion exercises to maintain flexibility and tactile stimulation to provide sensory reeducation. Primary surgery consists of microsurgical nerve surgery, whereas secondary surgery consists of alternative microsurgical procedures, tendon transfers, or osteotomies, all of which improve outcomes in the short term. However, the long-term outcomes of current treatment recommendations remain unknown.

Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis

Surgical release of the transverse carpal ligament for the treatment of carpal tunnel syndrome (CTS) is, in general, a very successful procedure. Some patients, however, fail this standard release and have persistent or recurrent symptoms. Such recalcitrance may relate to incomplete release but more often relates to perineural or intraneural fibrosis of the median nerve. While there is no good treatment for intraneural fibrosis, numerous procedures have evolved in an attempt to treat perineural fibrosis which restricts nerve gliding. These include procedures to isolate the nerve from scar as well as procedures to bring neovascularization to the median nerve. This review describes the various surgical treatment options for recalcitrant CTS as well as their reported outcomes.

Current concepts: neonatal brachial plexus palsy.

1. Explain how to diagnose infants with birth-related brachial plexus injuries. 2. Describe the classification system used to characterize brachial plexus injuries. 3. List the indications for microsurgical intervention for brachial plexus birth.

Physeal arrest of the distal radius.

Fractures of the distal radius are among the most common pediatric fractures. Although most of these fractures heal without complication, some result in partial or complete physeal arrest. The risk of physeal arrest can be reduced by avoiding known risk factors during fracture management, including multiple attempts at fracture reduction. Athletes may place substantial compressive and shear forces across the distal radial physes, making them prone to growth arrest. Timely recognition of physeal arrest can allow for more predictable procedures to be performed, such as distal ulnar epiphysiodesis. In cases of partial arrest, physeal bar excision with interposition grafting can be performed. Once ulnar abutment is present, more invasive procedures may be required, including ulnar shortening osteotomy or radial lengthening.

Complications of Distal Radial and Scaphoid Fracture Treatment

Fractures of the distal radius and the scaphoid are common injuries in adults. In recent years, surgical fixation of these types of fractures has increased in response to improved patient outcomes and evolving fixation techniques. Potential soft-tissue, neurovascular, or osseous complications, including tendon injuries, carpal tunnel syndrome, loss of fracture reduction, and osteonecrosis, can increase the time the patient requires immobilization and can lead to poor patient outcomes. Prompt recognition and diagnosis of these complications may improve patient outcomes and satisfaction.

Septic Olecranon Bursitis

n i HE PATIENT 40-year-old man who works as a carpenter presents o the emergency room with a 2-day history of increasng pain, swelling, and erythema of his posterior elbow. he patient reports bumping his elbow on a piece of ood while hammering 3 days ago. Our examination oted no open wounds. A fever of 101°F is recorded, ut the patient’s vital signs are otherwise normal. Elow motion is nearly full and painful with elbow flexon beyond 70°. The emergency room physician reuests a consultation for presumed septic olecranon ursitis.

Arthroscopic hemiresection for stage II-III trapeziometacarpal osteoarthritis.

Trapeziometacarpal osteoarthritis is a common problem, due to the anatomy of the first ray and the forces applied to the trapeziometacarpal joint throughout activities of daily living. Numerous treatment options exist, and continue to be developed, for this problem. The current goal is to eliminate pain and restore function and strength in a timely manner. New advances allow for earlier return to function with minimally invasive techniques. Arthroscopic hemitrapeziectomy combined with interposition arthroplasty and/or suspensionplasty is a treatment option for Stage II and III trapeziometacarpal arthritis that uses a minimally invasive technique and allows for earlier return of function.

Surgical Anatomy of the Supraclavicular Brachial Plexus.

BACKGROUND Brachial plexus exploration is performed in infants when addressing birth palsies and in children and adults following trauma. The upper trunk is most often injured. Traditional drawings of the brachial plexus depict the suprascapular nerve as a branch of the midportion of the upper trunk, with the more lateral branch of the upper trunk as the anterior division. We have not found this orientation to be accurate in clinical practice. The purpose of this study was to determine the branching patterns of the upper trunk and to delineate nerve orientations at the level of the divisions. METHODS Bilateral brachial plexus dissections were performed on eight adult cadavers. The length of the upper trunk and distance of the takeoff of the suprascapular nerve from the anterior and posterior divisions was measured. The native positions of the divisions and of the suprascapular nerve from lateral to medial were recorded across all trunks. RESULTS In six (38%) of the sixteen specimens, a trifurcation was found at the level of the upper trunk. The suprascapular nerve was the most lateral structure at the clavicular level in all specimens, followed by the posterior division and then the anterior division. The mean distance of the takeoff of the suprascapular nerve was 4 mm proximal to the branch point of the divisions; however, in two specimens, the nerve was found to take off from the posterior division proper. CONCLUSIONS These findings differ from the standard illustrations and descriptions of the brachial plexus. A thorough understanding of the course of the upper trunk and its branches, such as the suprascapular nerve, is vital to performing nerve transfer surgery or neuroma excision and grafting.

Outcomes Using Titanium Elastic Nails for Open and Closed Pediatric Tibia Fractures

The authors conducted a retrospective review at their level I trauma center to assess the outcomes of closed vs open pediatric tibial fractures treated with titanium elastic nails. The study group included 38 pediatric patients (median age, 12 years) treated with titanium elastic nails for tibial fractures during a 5-year period. Patient demographics, closed or open injury, Gustilo-Anderson type for open fractures, fracture location, skeletal maturity, time to union, hospital length of stay, number of procedures performed per patient, and complications were recorded. The main outcome measures were time to union and complications. Average follow-up duration was 13 months. Mean time to union was 4 months for closed and 9 months for open fractures (P<.001). Average time to union for type IIIA and IIIB fractures was significantly increased (11 and 12 months, respectively; P=.02). Delayed union (>6 months postoperatively) occurred in 1 (6%) of 17 closed fractures compared with 11 (52%) of 21 open fractures. The average number of surgical procedures for closed fractures was fewer than for open fractures (2 vs 3 procedures, respectively; P=.03). Mean hospital length of stay was shorter for closed than open fractures (3 vs 6 days, respectively; P=.03). Two infections occurred in the open fracture group. Closed and open pediatric tibial shaft fractures can be successfully treated with titanium elastic nails. Open fractures treated with titanium elastic nails have a significantly longer time to union, require additional operative procedures, and result in longer hospital stays.