Kelly D. Carmichael

Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures.

Recent reports have shown that some displaced supracondylar humerus fractures can be treated in a delayed fashion the day following injury and complication rates will not be increased. This study determined if the quality of the reduction, as determined by restoration of Baumanns angle, is affected by surgical timing. Forty two patients ranging in age from 2 to 12 years were treated. Delayed intervention was defined as > 8 hours post-injury. Acute intervention occurred in 25 patients with a mean age of 5.5 years. Delayed intervention occurred in 17 patients with a mean age of 5.8 years. Baumanns angle was restored to within an average of 2.2 degrees of the contralateral elbow in the acute group and to within 1.2 degrees in the delayed group. Gartland type 2 fractures were more likely to be delayed in this retrospective study and these fractures showed better improvements in Baumanns angle restoration than did type 3 injuries when treated in a delayed fashion. In type 2 injuries and type 3 injuries without neurovascular compromise, delaying operations until the next morning will not compromise the quality of the reduction.

Relation of residency selection factors to subsequent orthopaedic in-training examination performance.

Objectives: Orthopaedic surgery remains one of the most competitive specialties, with more than a 99% match fill rate in the past several years. An oversupply of qualified applicants leads to intense competition for these residency spots, allowing program directors to be more selective in choosing their future residents. Although many previous studies have documented factors important to program directors in the admission process, less is known about how preselection factors correlate with subsequent performance in a residency program. Methods: The relation of both demographic and academic factors with subsequent performance on the Orthopaedic In-Training Examination (OITE) were studied. These factors include United States Medical Licensing Examination (USMLE) step I scores, Alpha Omega Alpha (AOA) status, research publications, age entering residency, marital status, and medical school affiliation. Results: In this study, the only statistically significant correlations to OITE scores were USMLE step I performance and marital status. Those residents who had previously scored above 220 on the USMLE step I had higher average OITE scores than those scoring below 220. Residents who were married also had higher average OITE scores. A trend with regard to AOA status also was found, with residents scoring slightly higher on the OITE if they were members of AOA. Conclusions: Few preresidency variables correlate to success during an orthopaedic residency.

Posterior sternoclavicular epiphyseal fracture-dislocation with delayed diagnosis

Posterior sternoclavicular joint dislocations and epiphyseal fractures are relatively rare injuries. We present a case report of a 16-year-old male who presented with a 10-day delay in diagnosis. The medial clavicular fragment was widely displaced and rested against the cervical vertebral body. Despite the degree of displacement, the patient had very few symptoms, and the diagnosis was not appreciated in the emergency department and became apparent at 10-day clinic follow-up. Treatment consisted of attempts at closed reduction, which were not successful. Open reduction was performed and the repair done with strong sutures. At 1-year follow-up the patient is doing well without any symptoms. A literature review consisting of anatomy, ossification patterns, classification systems, diagnosis and associated symptoms, imaging recommendations, treatment recommendations, outcomes, and complications is included.

Familial tumoral calcinosis: A forty-year follow-up on one family

BACKGROUND Familial tumoral calcinosis is a rare autosomal recessive disorder that was first described well in a report on four patients from one family in 1969. The disease leads to periarticular ectopic calcifications. The original report described patients from black, healthy, unrelated parents with sixteen children, seven of whom had the disease. METHODS On the basis of retrospective chart reviews and interviews with surviving family members, we describe the long-term follow-up of this one family, encompassing as long as forty years. Of the sixteen siblings, seven had tumoral calcinosis. RESULTS All seven affected children had hyperphosphatemia. There were two subsequent generations comprising thirteen children and seven grandchildren with no instances of tumoral calcinosis. The seven affected patients were followed for as many as forty years and underwent an average of twenty-one operations (range, four to thirty-six operations) for the treatment of calcified lesions. The genetic defect has been identified as the GALNT3 gene, thus leading to the hyperphosphatemic form of the disease. Although two of the patients had died by the time of the present study, the remaining five provided accounts of the disease course, the response to surgery and to medical therapy, and the effect of therapy on their lives. Some members had relatively few lesions and surgical procedures (as few as four), whereas others had an unrelenting course of lesions, recurrences, and surgical procedures (as many as thirty-six, with numerous other procedures). Three patients had multiyear periods with few symptoms--one for seven years, one for twelve years, and one for fifteen years. No effective medical therapy was found to control the lesions, and operations were associated with a high recurrence rate. CONCLUSIONS Familial tumoral calcinosis has a varied natural history; some patients have an unrelenting course, while others may experience quiescent periods. The GALNT3 gene is responsible for the hyperphosphatemic form as seen in this family. Molecular testing may be of benefit to members of affected families, and future studies may help to explain the phenotypic variability among affected individuals. No medical or surgical treatment plan seemed to be effective for controlling the lesions in this family.

Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with ilizarov fixation

The purpose of this study was to determine recurrence rates of pediatric foot and ankle burn deformities treated with the Ilizarov method. A total of 19 patients with 29 foot and ankle deformities were studied. The most common deformity treated was equinus (23). Rocker-bottom and cavus foot deformities were each treated three times. The average age of the patient at the time of the burn injury was 3.2 years, and the average age at the time of fixation was 9.4 years. Equinus contractures averaged −34 degrees (34 degrees of plantarflexion) before surgery and +7 degrees (7 degrees of dorsiflexion) after treatment with the Ilizarov fixator. The recurrence rate for all 29 ankles and feet was 69% (20/29). The recurrence rate for equinus contractures was 74% (17/23). The average time to recurrence was 17.3 months. Only short-term follow-up was available on four of the six feet and ankles that did not recur. Deformity correction in burned feet and ankles is difficult to obtain by any means. The authors recommend using the Ilizarov method to obtain correction of moderate to severe foot and ankle deformities in pediatric burn patients, but the correction obtained is not stable and deformity will likely recur. Parents and patients should anticipate adjunctive nonoperative and operative procedures to keep their feet plantigrade as they grow. In young children, the possibility of having additional surgeries, including repeat Ilizarov procedures, should be discussed. Even older children should expect additional surgeries to prevent recurrent deformities.

Incidence of pin track infections in children's fractures treated with kirschner wire fixation

Smooth Kirschner wires (K-wires) are frequently used in pediatric orthopaedics; however, the infection rate associated with these devices is not known. A retrospective study on infection rates in pediatric patients who had fractures treated with percutaneous smooth K-wire fixation was performed. A total of 202 patients with an average age of 9.7 years were included in the study. Upper extremity fractures made up 93% of the cases. The overall infection rate was 7.9%. The classification system of Green was used to describe major and minor infections. There were 16 infections noted; 12 (5.9%) of these were minor, and 4 (2%) were major. Infection rates did not correlate with length of fixation. There was also no correlation of increased infection rates with open fractures or fractures that required open reduction. The infection rates associated with the use of smooth K-wires in pediatric fracture patients is low. The major infection rate is only 2% and does not correlate to length of fixation or type of fracture.

Outcomes assessment of pediatric both-bone forearm fractures treated operatively.

This study assessed the outcome of pediatric both-bone forearm fractures treated with operative intervention. A retrospective review was conducted of 31 patients treated over a 40-month period. Fifteen patients were treated with flexible intramedullary nailing and 16 treated with open reduction and internal fixation. Average patient age was 11 years (range: 3.8-17.9 years). Operative indications included 2 open fractures and 29 fractures with unacceptable reductions. The intramedullary nailing group had 14 excellent results and 1 good result. The open reduction internal fixation group had 15 excellent results and 1 good result. Overall, 29 (93.5%) of 31 patients had excellent results. Two minor complications occurred in the intramedullary nailing group and none in the open reduction internal fixation group. Although operative intervention in pediatric both-bone forearm fractures is rarely indicated, when necessary, good results can be expected.

Biceps Muscle Rupture in a Water Skier

Rupture of the biceps muscle is an unusual injury; however, it should be considered in the differential diagnosis of a distal tendon rupture.

Biomechanical study of flexible intramedullary nails.

Background: Flexible intramedullary (IM) nailing is considered a safe, minimally invasive fixation technique with relatively low complication rates for long-bone fractures in the pediatric population. At our institution, questions have arisen about stability of fixation based on the distance of the nail past the fracture site. Clinically, this question arises with proximal or distal fractures and when the nail is unable to be passed to the desired distance past the fracture site. The purpose of our study was to compare biomechanical resistance with bending forces for fixation constructs whose IM nails are at differing distances beyond the fracture site in different bones. Methods: This study tested matched pairs of canine radii, ulnas, and tibias in 4-point bending and compared the biomechanical properties of length of nail fixation past the fracture site in relation to bone diameter. Results: Fixations of 1 or 2 diameters past the osteotomy yielded gross instability. There was no difference found in bending failure force, displacement, stiffness, or energy when comparing 3 versus 5 diameters of fixation past the fracture site. Conclusions: Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more beyond the fracture site, the length does not significantly affect the biomechanical properties of the construct. Clinical Relevance: Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more past the fracture site, the length of the nail does not greatly affect the biomechanical properties of the construct. This knowledge may be helpful in clinical scenarios where there is uncertainty about the expected strength of a shorter fixation. Examples include when the nail cannot be passed completely to the distal metaphysis and in proximal or distal long-bone fractures. Further clinical studies are needed to determine implications in a patient setting.

The Use of Ultrasound to Determine Timing of Pavlik Harness Discontinuation in Treatment of Developmental Dysplasia of the Hip

The timing of Pavlik harness removal in patients with developmental dysplasia of the hip is typically determined by clinical examination. Ultrasound is considered more sensitive than clinical examination in diagnosis of instability of the hip, but it is not routinely used in cases of developmental dysplasia of the hip, especially when determining the timing of Pavlik harness removal. The purpose of this study is to investigate if ultrasound examination is more effective than clinical examination alone in determining completion of Pavlik harness treatment. Fifty consecutive infants with developmental dysplasia of the hip were given both a clinical examination and dynamic ultrasound examination to determine if Pavlik harness treatment could be discontinued. A pediatric orthopedist conducted the physical examinations. Both a radiologist and a pediatric orthopedist interpreted the ultrasounds. Cost estimates for ultrasound and operative procedures were obtained at our institution and compared. The average age at the time of Pavlik harness placement was 5.3 days, and the average age at the time of ultrasound was 54.3 days. There were 35 females and 15 males and 31 left hips, 4 right hips, and 15 bilateral hips. All 50 patient hips were deemed clinically stable prior to obtaining an ultrasound. The ultrasound interpretations by a radiologist and pediatric orthopedist were in agreement in all cases. In one case, the ultrasound results did not correlate with results of the clinical examination. In that one case, the hip was clinically stable, but dynamic ultrasound revealed that the hip was located, but dislocatable. The Pavlik harness was reapplied to the patient for an additional 42 days. At 1-year follow-up the hip is stable and developing normally as determined by radiographs. The cost comparison revealed that the cost of 50 ultrasounds is less than the cost of a single operative procedure. The use of ultrasound to determine the timing of Pavlik harness cessation is justified from both a financial and a patient outcome perspective in this small study. Larger studies are needed before ultrasound examination used to help determine Pavlik cessation is considered standard of care.