Kelly L. Vander Have

Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents.

Background Midshaft clavicle fractures in adolescents have traditionally been treated nonoperatively. Recent studies in the adult literature have shown a higher prevalence of symptomatic malunion, nonunion, and poor functional outcome after nonoperative treatment of displaced fractures. The purpose of this study was to compare operative versus nonoperative treatment of displaced clavicle fractures in adolescents. Materials and Methods Adolescents who sustained closed midshaft clavicle fractures between 2000 and 2008 were identified in our institutional trauma registry. Medical records were reviewed for patient demographics, injury characteristics, treatment, and outcomes. Results Forty-two consecutive patients (mean age 15.4 y) with 43 closed midshaft clavicle fractures were identified. Twenty-five patients were treated nonoperatively with a sling or figure-of-8 brace. Seventeen patients were treated operatively with acute plate fixation for fractures displaced more than 2 centimeters. The average shortening at injury was 12.5 mm in the nonoperative group and 27.5 mm in the operative group (P=0.003). The mean time to radiographic union for displaced fractures was 8.7 weeks in the nonoperative group and 7.4 weeks in the operative group (P=0.02). There were no nonunions in either group. All complications in the operative group were related to local hardware prominence. The mean time to return to activities was 16 weeks in the nonoperative group and 12 weeks in the operative group. Symptomatic malunion, with a mean fracture shortening of 26 mm, developed in 5 patients in the nonoperative group. Four of these patients elected corrective osteotomy with internal fixation and all went on to union with resolution of their symptoms. Conclusions Plate fixation of displaced midshaft clavicle fracture reliably restores length and alignment. It resulted in shorter time to union with low complication rates. Symptomatic malunion in adolescents may be more common than earlier thought after significantly displaced fractures. Corrective osteotomy with plate fixation can restore clavicle anatomy and eliminate symptoms associated with malunion. Level of Evidence Therapeutic level III.

Community-associated methicillin-resistant Staphylococcus aureus in acute musculoskeletal infection in children: a game changer.

Background Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a virulent pathogen responsible for an increasing number of invasive musculoskeletal infections in healthy children. The purpose of this study is to characterize the presentation, clinical course, treatment, complications, and long-term morbidity of CA-MRSA musculoskeletal infection in children. Methods A retrospective study of children with CA-MRSA musculoskeletal infections from 2 institutions was conducted. Results The study group included 27 patients. Clinical presentation involved an extremity in 23 of 27 patients. Twelve patients required admission to the intensive care unit. Four of these patients developed acute multisystem failure. Magnetic resonance imaging was obtained in 21 patients and was diagnostic in all. Seven patients developed deep venous thrombosis and septic pulmonary emboli. All patients required surgical intervention, and 16 of 27 required multiple debridements. Conclusions CA-MRSA is limb and life threatening. Prompt recognition and treatment are critical. Aggressive surgical drainage/debridement in addition to long-term antibiotics is required. There is significant potential for long-term morbidity despite aggressive management. Level of Evidence Level IV, retrospective case series.

Arthrofibrosis After Surgical Fixation of Tibial Eminence Fractures in Children and Adolescents

Background Tibial eminence fractures are rare injuries in children and adolescents. Displaced fractures require reduction and fixation. Operative stabilization can be accomplished with either open or arthroscopic reduction and fixation. Whereas loss of extension has been reported, there are no reports in the literature that quantify loss of motion or provide guidance for treatment. Purpose To report a series of patients who developed knee stiffness after operative treatment for displaced tibial eminence fractures. Study Design Case series; Level of evidence, 4. Methods Review of medical records and imaging studies of pediatric patients with displaced tibial eminence fractures who developed arthrofibrosis after surgical intervention. Results Thirty-two patients were identified. Twenty-four required reoperation for loss of flexion (n = 9), loss of extension (n = 4), or both (n = 11). Manipulation under anesthesia resulted in distal femoral fractures and subsequent growth arrest in 3 patients. Twenty-nine patients were able to achieve near full knee motion at final follow-up. Conclusions Children with tibial spine fractures are at risk for arthrofibrosis. Stabilization of the fracture is important to allow early postoperative rehabilitation. Should stiffness occur, manipulation of the knee should be performed only in conjunction with lysis of adhesions.

Increased Intracapsular Pressures After Unstable Slipped Capital Femoral Epiphysis

Background: Osteonecrosis of the femoral head is the most dreaded complication associated with an unstable slipped capital femoral epiphysis (SCFE). We hypothesize that the hip joint pressure will be increased in unstable slips, confirming that emergent treatment and decompression are warranted. Methods: Thirteen unstable SCFE hips were evaluated. Hip pressure monitoring was performed. Postcapsulotomy measurements were also performed in all of the patients. Five of these under gentle manipulation. Six patients underwent measurement of the hip pressure on the unaffected side. Results: The mean pressure on the affected hip was 48 mm Hg. The mean pressure on the unaffected side was 23 mm Hg. There was a significant increase in intraarticular hip pressure after attempted manipulation (mean, 75 mm Hg). Discussion: Hip pressures are increased in unstable SCFE to levels higher for those of a compartment syndrome probably causing a tamponade effect. There is a need to perform a capsulotomy if manipulation is performed.

Stabilization of adolescent both-bone forearm fractures: a comparison of intramedullary nailing versus open reduction and internal fixation.

Objectives: To compare flexible intramedullary (IM) nailing with open reduction and internal fixation (ORIF) with plates and screws in the treatment of adolescent both-bone forearm fractures. Design: Retrospective comparative study. Setting: Level I trauma center. Patients/Participants: Sixty-one skeletally immature adolescents (mean age, 13.9 years; range, 11.5-16.9 years) treated operatively for both-bone forearm fractures from 1997 to 2007. Patients with Monteggia, Galeazzi, intra-articular, and pathologic fractures were excluded. Intervention: Forty-six patients (mean age, 14.1 years) underwent ORIF and 15 patients (mean age, 13.3 years) underwent flexible IM nailing. Main Outcome Measures: Time to fracture union, forearm rotation, magnitude and location of maximal radial bow, and complications. Results: There was no difference in mean time to union between the IM nailing (8.5 weeks) and ORIF (8.9 weeks) groups, although the study did not have sufficient power to detect a difference. Eighty-three percent of patients in both groups regained full forearm rotation. Although radial bow magnitude was comparably restored in both groups, the mean location of maximal radial bow was translated distally in the IM nailing group (67.2%) compared with the ORIF group (60.1%, P < 0.001) and a previously reported normal value (60.4%, P < 0.001). There were no major complications in the IM nailing group and five major complications in the ORIF group. Conclusions: Flexible IM nailing of both-bone form fractures in adolescents was safe and effective in our small series; we had less complications when compared with conventional ORIF. Although flexible IM nailing results in distal translation of the radial bow, forearm rotation is not compromised.

Retrospective study on the development of spinal deformities following sternotomy for congenital heart disease.

Study Design. Retrospective review with a minimum of 3 years of follow-up. Objective. We hypothesize that following median sternotomy there may be an increase incidence of both sagittal and coronal spinal deformity. We also think that heart size and a cyanotic cardiac condition are also risk factors for development of spinal deformity. The purpose of this study was to determine the incidence and characteristics of spinal deformity in patients following sternotomy for congenital heart disease. Summary of Background Data. Patients with congenital heart disease are at an increased risk to develop scoliosis. Methods. A total of 108 patients underwent a median sternotomy for the treatment of congenital heart disease and met inclusion criteria. The medical record was reviewed to gather demographic data and medical and surgical history. Serial chest and spine radiographs were reviewed. Results. Scoliosis developed in 28% of the patients (10 males, 20 females). The mean follow-up was 13 years (range, 3–26 years). The mean coronal Cobb angle was 25° (range, 11°–88°). Of these, 7 patients presented with curves of ≥30°. The mean age at diagnosis of scoliosis was 14 years (range, 2–33 years). A kyphotic deformity developed in 22% (24 patients). In patients with scoliosis, the mean sagittal kyphosis was 34° (range, 2°–73°). Patients with a cyanotic cardiac condition had a trend toward severe scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, gender, or heart size. Conclusion. The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or kyphosis, were found in 34% of the patients. The sagittal alignment in scoliosis patients tends toward kyphosis.

Congenital pseudarthrosis of the tibia.

Congenital pseudarthrosis of the tibia is characterized by anterolateral deformity of the tibia and shortening of the limb. Its etiology remains unclear. Although several classification systems have been proposed, none provides specific guidelines for management. Treatment remains challenging. The goal is to obtain and maintain union while minimizing deformity. The basic biologic considerations with surgical intervention include resection of the pseudarthrosis and bridging of the defect with stable fixation. Intramedullary stabilization, free vascularized fibula, and Ilizarov external fixation are among the most frequently used methods of treatment. In addition, bone morphogenetic protein recently has shown promise. Nevertheless, despite improvements in healing rates with congenital pseudarthrosis of the tibia, the potential for amputation in failed cases persists.

Burst fractures of the thoracic and lumbar spine in children and adolescents.

Background Burst fractures are rare in the pediatric population. There is limited information available on the best treatment for these injuries. The aims of our study were to evaluate the risk of spinal cord injury (SCI) and the potential for neurologic recovery associated with pediatric burst fractures; to compare sagittal alignment between nonoperative and operative treatment; and to determine whether functional outcomes are improved after surgery. Methods All pediatric patients who sustained thoracic or lumbar burst fractures at 2 institutions between 1991 and 2005 were identified. The medical records were reviewed for patient demographics, injury, treatment, and outcomes. Health Survey data were collected from a subset of patients in both the operative and nonoperative groups. Results Thirty-seven patients met the inclusion criteria. There were 17 male patients and 20 female patients, with an average age of 14.6 years (range, 6 to 18 y). Nine patients were treated nonoperatively and 28 patients were treated operatively. The nonoperative group was treated with hyperextension casting or bracing and showed progression of kyphotic deformity from 16.1 degrees at injury to 23.1 degrees at final follow-up. In patients treated operatively, the kyphotic deformity improved from 17.1 degrees at presentation to 7.2 degrees at final follow-up. Twenty-four patients were neurologically intact at presentation, whereas 13 presented with neurologic deficit. Six of 13 patients with SCI had some improvement. The risk of SCI was highest in patients with thoracic-level fractures. The risk of SCI did not correlate with canal compromise. There were no significant differences in functional outcome between the 2 groups. Conclusions The risk of neurologic injury in pediatric burst fractures of the spine may be more closely related to the level of injury (thoracic) than the degree of spinal canal compromise. Prognosis for recovery of neurologic injury is related to the severity of the initial neurologic injury. Level of Evidence Prognostic level 2.

Ossifying lipoma of c1-c2 in an adolescent.

Background Ossifying lipomas, characterized by their independence of bony connection to the skeleton, are extremely rare benign neoplasms. They have primarily been described in adults older than 50 years of age and occur in the head and neck region. The etiology is unknown. Excision is the preferred treatment. The objective of this study is to report the case of a rare ossifying lipoma immediately anterior to C1 to C2, requiring a transoral approach for excision. Methods The case of an adolescent with a retropharyngeal mass is described. Results A 15-year-old female patient presented with an asymptomatic parapharyngeal mass detected on routine physical examination. Computed tomography and magnetic resonance imaging noted a calcified, left-sided, parapharyngeal mass, approximately 3×2×2 cm3, anterior to C1 and C2, most consistent with a benign osseous lesion. A transoral approach was used to excise the mass. Histologic examination demonstrated an ossifying lipoma. Postoperative imaging confirmed complete excision. The postoperative course was unremarkable, and the patient has had no recurrence at 6-month follow-up. Conclusions This case demonstrates that a transoral approach to a lesion anterior to C1 to C2 in an adolescent can be safe, complete, and effective. Level of Evidence Case Report, level 5.

Isolated alar ligament disruption in children and adolescents as a cause of persistent torticollis and neck pain after injury. A report of three cases

The alar ligaments are small paired spinal ligaments that attach from the occiput to the proximal portion of the odontoid process of the second cervical vertebra (C2). Injury to the upper cervical spine in children is infrequent, and isolated injury of the alar ligaments is even more uncommon, with only a report of two cases, in German, appearing in the literature1. Here we describe isolated alar ligament disruptions in three children. This injury caused persistent torticollis and neck pain in which neither fracture nor anterior or posterior listhesis was detected on radiographic studies. The injury did not lead to instability in the upper cervical spine in any of the patients. Medical records and radiographs of three patients with isolated alar ligament disruption were reviewed. Data collected included age of the patient at the time of injury, mechanism of injury, presentation of the patient, method of treatment, time to healing, complications, post-treatment physical therapy, and final range of motion of the neck. This report includes case descriptions and radiographic studies of these three patients. We attempted to contact our patients and, when possible, our patients were informed that data concerning their cases would be submitted for publication. The protocol for this case series was reviewed by our institutional review board and was given exempt status. Case 1. A seventeen-year-old female pedestrian was struck by a motor vehicle and sustained a painful neck injury and a fractured femur. Radiographs revealed that the thoracic and lumbar spine were normal. Computed tomography scans demonstrated widening of the space between the dens and the C1 left lateral mass (Fig. 1-A). Magnetic resonance imaging showed hyperintensity to the left of the dens, indicating edema and ligamentous injury (Fig. 1-B). The injury to the cervical spine was treated with halo immobilization for twelve weeks, …