Matthew R. Garner

Eleven years experience in the operative management of pediatric forearm fractures.

Background There has been a trend toward operative management of pediatric diaphyseal forearm fractures (DFFx). We studied our experience with surgical management of these injuries to assess indications, frequency, outcome, and complications. Methods One hundred forty-four consecutive children had surgical management of 149 DFFx over 11 years at our Level 1 pediatric trauma center. A chart/radiographic review established perioperative events, intraoperative findings, time-to-union, range-of-motion, and complications. We developed the Childrens Hospital of Philadelphia Forearm Fracture Fixation Outcome Classification to assess postoperative outcomes. Results Over 11 years, we treated 2297 DFFx; 155 of 2297 (6.7%) had surgical management. Six were lost to follow-up and excluded. A 7-fold increase in operative management was observed over the study period [2 of 143 (1.4%) vs. 28 of 270 (10.4%), P<0.001]. One hundred and three of 149 (69.1%) were treated with intramedullary nailing (IMN); 44 of 149 (29.5%) with plates; and 2 of 149 (1.3%) had combined plate/nail fixation. Thirty of 103 (29.1%) had the fracture site opened to pass the IMN; in 23 cases, open fractures were exploited to assist nail passage. When managed with IMN, open fracture sites showed slowed healing: union was 8.6 weeks for those opened intraoperatively and 6.9 weeks for those remaining closed (P<0.001). Fractures opened secondary to injury achieved union at 9.75 weeks which was significantly longer than those opened intraoperatively (8.6 wk, P=0.04) and those remaining closed (6.9 wk, P=0.001). Compartment syndrome occurred in 6.7% (2 of 30) treated with IMN within 24 hours of injury versus 0 of 73 treated later (P=0.026). Delayed union after IMN occurred in 6 children 10 years of age versus none less than 10 years of age. Poor/fair outcome of IMN increased with age [6 of 47 (13%) ≤10 y of age, vs. 17 of 56 (30%)>10 y of age, P=0.03]. Overall complication rate for IMN was 14.6% (15 of 103). Conclusions Our center has operatively managed DFFx with increased frequency over the past decade. IMN had a complication rate of 14.6% and was frequently not “minimally invasive.” An open fracture site delayed healing. Compartment syndrome was more frequent when IMN was used the day of injury and older children had poorer outcomes and higher rates of delayed union. Level of Evidence Level III, Retrospective Comparative Study.

Acute Traumatic Compartment Syndrome of the Leg in Children: Diagnosis and Outcome

BACKGROUND Currently, the most common clinical scenario for compartment syndrome in children is acute traumatic compartment syndrome of the leg. We studied the cause, diagnosis, treatment, and outcome of acute traumatic compartment syndrome of the leg in children. METHODS Forty-three cases of acute traumatic compartment syndrome of the leg in forty-two skeletally immature patients were collected from two large pediatric trauma centers over a seventeen-year period. All children with acute traumatic compartment syndrome underwent fasciotomy. The mechanism of injury, date and time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded. RESULTS Thirty-five (83%) of the forty-two patients were injured in a motor-vehicle accident and sustained tibial and fibular fractures. The average time from injury to fasciotomy was 20.5 hours (range, 3.9 to 118 hours). In general, the functional outcome was excellent at the time of the latest follow-up. No cases of infection were noted when fasciotomy was performed long after the injury. At the time of the latest follow-up, forty-one (95%) of forty-three cases were associated with no sequelae (such as pain, loss of function, or decreased sensation). The two patients who lost function had fasciotomy 82.5 and eighty-six hours after the injury. CONCLUSIONS Despite a long period from injury to fasciotomy, most children who are managed for acute traumatic compartment syndrome of the leg have an excellent outcome. This delay may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. The results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury. Fasciotomy during the acute swelling phase, even long after injury, produced excellent results with no cases of infection.

Fixation of length-stable femoral shaft fractures in heavier children: flexible nails vs rigid locked nails.

Background The treatment of femoral shaft fractures in heavier children has been studied extensively, however, no study has directly compared elastic nail (TEN) and rigid locking nails (RLN) in this population. Our goal was to compare TEN with RLN in length-stable diaphyseal femur fractures in heavier children and adolescents (47 to 85 kg) using weight-matched cohorts. Methods We retrospectively reviewed records for length-stable diaphyseal femoral fractures treated with TEN or RLN over 8 years at our Level 1 Pediatric Trauma Center. Perioperative and follow-up data, including total charges for care, were recorded and radiographic images were reviewed. These data were used to create 2 cohorts having each patient in the TEN cohort matched to within 2 kg of the corresponding patient in the RLN cohort. Results Fifteen patients from each cohort could be weight matched (TEN, 60.8 kg vs. RLN, 60.4 kg). The RNL cohort was older (15.4 vs. 13.5 y; P=0.005). Time in operating room and estimated blood loss were greater in the RLN cohort: 158 versus 220 minutes (P=0.003) and 42 versus 182 ml (P=0.003), respectively. All patients had a full range of motion at the latest follow-up. Complications were observed in 6 of 15 TEN and 10 of 15 RNL (P=0.14). Implant-related problems were more common in RLN patients, but this was not statistically significant (3 of 15 vs. 9 of 15; P=0.06). In the TEN cohort, malunion and leg length discrepancy (>2 cm) each occurred in a single patient (20 degrees varus, 2.3 cm shortening, respectively) compared with 0 of 15 in RLN (P=0.48). Treatment with TEN resulted in a total charge of

Embolization of Renal Artery Aneurysm and Arteriovenous Fistula A Case Report

742 more than RLN (P=0.75). Conclusions In our weight-matched comparison, the use of TEN resulted in decreased time in operating room, estimated blood loss, and implant-related problems. Malunion and leg length discrepancy remain of concern when heavier patients are treated by TEN, but were not significantly increased relative to RNL in this study.

The Measurement and Clinical Importance of Syndesmotic Reduction After Operative Fixation of Rotational Ankle Fractures

A renal artery aneurysm with an associated arteriovenous fistula in a native kidney has been reported infrequently in the literature. Management depends on size, location, and the patients physiological condition. We describe a case in which endovascular therapy was used to successfully exclude both aneurysm and fistula. This report describes a 13-centimeter renal artery aneurysm with arteriovenous fistula originating from an isolated branch of the renal artery. Coil-embolization resulted in thrombosis of the aneurysm and fistula while preserving parenchymal perfusion. Coil embolization is an alternative to surgery for coexistent renal artery aneurysm and arteriovenous fistula arising from a branch of adequate length for placement of embolic coils. Successful treatment is not limited by aneurysm size or presence of arteriovenous connection.

The Treatment of Low-Energy Femoral Shaft Fractures: A Prospective Study Comparing the “Walking Spica” with the Traditional Spica Cast

BACKGROUND Rotational ankle fractures often have unstable syndesmotic injuries that require reduction and stabilization. Multiple studies have focused on methods to assess syndesmotic reduction; however, the clinical importance of anatomic syndesmotic reduction remains unclear. The purpose of this study was to determine whether the quality of syndesmotic reduction influenced clinical outcomes following operative treatment of ankle fractures with unstable syndesmotic injuries. METHODS Patients were included from an institutional trauma registry if they had sustained rotational ankle fractures with intraoperative evidence of syndesmotic instability requiring syndesmotic reduction and stabilization. Patients with at least twelve months of disease-specific, patient-reported clinical outcomes were included. Computed tomography (CT) imaging of both ankles was performed within two days postoperatively for all patients. Four previously utilized methods of assessing syndesmotic reduction using axial CT images of the operatively treated and the contralateral ankle were used. RESULTS A total of 155 patients met the study inclusion criteria and underwent analysis. The four methods used to assess syndesmotic reduction had reliabilities ranging from moderate to almost perfect (intraclass correlation coefficient [2,1] range = 0.544 to 0.821). Measurements of the uninjured syndesmosis were consistent with those in several previous studies of normal syndesmotic morphology, and the four methods of syndesmotic assessment had strong internal consistency. The mean measurement differences between the injured and normal ankles ranged from 1.32 to 1.88 mm of displacement and averaged 5.75° of rotation. There were no correlations noted between any of the four syndesmotic reduction assessment methods and any Foot and Ankle Outcome Score domains. CONCLUSIONS Within the range of syndesmotic malreductions studied, the quality of syndesmotic reduction did not significantly influence clinical outcomes. These results challenge previous definitions of syndesmotic malreduction and the clinical importance of minor syndesmotic changes. It remains unclear, however, whether greater magnitudes of syndesmotic malreduction than those seen in this cohort would lead to inferior patient-reported outcomes.

Anatomic Ligament Repair Restores Ankle and Syndesmotic Rotational Stability as Much as Syndesmotic Screw Fixation.

BACKGROUND A single-leg, walking hip spica cast has been shown to be a safe and effective treatment for a low-energy femoral shaft fracture in young children. We designed a prospective cohort trial comparing walking and traditional hip spica casting to determine whether a walking hip spica cast was superior to a traditional hip spica cast following a low-energy femoral shaft fracture in children one to six years old. METHODS We studied forty-five consecutive low-energy femoral shaft fractures during a three-year period in children one to six years old. Three surgeons treated their patients with a walking hip spica cast, and three other surgeons treated their patients with a traditional spica cast. Complications and subsequent interventions were recorded prospectively. Caregivers were asked to complete the validated Impact on Family Scale as well as a ten-item questionnaire developed by the authors at the time of cast removal. RESULTS Forty-five patients with a low-energy fracture were enrolled in the study. Nineteen patients were treated with a walking hip spica cast and twenty-six, with a traditional hip spica cast. The two cohorts were similar with respect to age, length of hospital stay, time to initial callus formation, and time to fracture union. Two children treated with a traditional hip spica cast and no children in the walking hip spica group returned to the operating room for the treatment of spontaneous loss of fracture reduction. Five of the nineteen children treated with a walking hip spica cast and one of the twenty-six treated with a traditional hip spica cast required wedge adjustment of the cast in the clinic to treat fracture malalignment (p = 0.04). One patient treated with a walking hip spica cast required repeat reduction in the operating room because of overcorrection during wedge adjustment. The malunion rate did not differ significantly between the groups (three of twenty-six in the traditional hip spica group compared with none of nineteen in the walking hip spica group). All patients treated with a walking hip spica cast were able to crawl in the cast, and 71% (twelve of seventeen) were able to walk. Use of the traditional hip spica cast resulted in a significantly greater care burden for the family as measured with use of the Impact on Family Scale (43.3 for the traditional hip spica group compared with 35.6 for the walking hip spica group, p = 0.04). Insurance-funded ambulance transportation was needed for eleven of the twenty-six patients treated with a traditional hip spica cast compared with none of the nineteen patients treated with a walking hip spica cast (p = 0.001). CONCLUSIONS The walking hip spica cast and the traditional hip spica cast resulted in similar orthopaedic outcomes, and the walking hip spica cast resulted in a lower care burden for the family. Surgeons and families should be aware that use of a walking hip spica cast rather than a traditional hip spica cast may be associated with a greater likelihood that wedge adjustment of the cast will be necessary to treat fracture malalignment.

Correlation Between the Lauge-Hansen Classification and Ligament Injuries in Ankle Fractures.

Objectives: To compare the external rotation stability of 3 different syndesmotic stabilization techniques in a cadaveric ankle fracture model. Methods: Nondestructive external rotation stresses of 4 N·m were applied to 8 cadaveric limbs using a hydraulic loading frame. Four conditions were tested using a repeated-measures design: intact and 3 repair conditions after a destabilizing ligamentous ankle injury with syndesmotic disruption. The 3 repair conditions were tricortical trans-syndesmotic screw fixation, posterior inferior tibiofibular ligament (PITFL) repair, and combined PITFL and deltoid ligament repair. External rotation of the ankle joint and syndesmosis was measured using a motion capture system and compared for each test condition. Repeated-measures 1-way analyses of variance statistical tests were performed to compare the ankle and syndesmotic rotation findings between the 3 repair conditions and intact condition. Results: Rotational ankle stability was not fully restored by any of the 3 repair constructs. The intact ankle joint externally rotated approximately half as many degrees as the 3 repair conditions (intact: 10.9; trans-syndesmotic screw: 17.0; PITFL: 21.4; and PITFL/deltoid: 15.6). The intact condition also demonstrated significantly fewer degrees of syndesmotic rotation than the repair constructs (intact 2.4; trans-syndesmotic screw 5.2; PITFL 8.5; and PITFL/deltoid 6.9). Each of the repair conditions resulted in an externally rotated fibula when no loads were applied. The ligamentous repairs externally rotated the fibula twice as much as the trans-syndesmotic screw (P < 0.016). Conclusions: We found that combined repair of the PITFL and deltoid ligament restores an equivalent amount of ankle and syndesmotic rotational stability when compared to trans-syndesmotic screw fixation. Based on our findings, ligamentous repair can potentially be a viable treatment alternative in unstable ankle fracture patients with syndesmotic disruption. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Compartment Syndrome: Diagnosis, Management, and Unique Concerns in the Twenty-First Century

Objective: To evaluate the ability of the Lauge-Hansen classification to predict ligament injuries in ankle fractures using magnetic resonance imaging (MRI) and intraoperative findings. Design: Prospective evaluation in consecutive patients. Setting: Academic level 1 trauma center. Patients: Three-hundred patients with an operatively treated ankle fracture who met the inclusion and exclusion criteria. Intervention: Injury ankle radiographs were assigned to a Lauge-Hansen classification. MRI scans were obtained to evaluate the syndesmotic and deltoid ligaments. A Lauge-Hansen classification for each patient was recorded based on intraoperative findings. Main Outcome Measurements: Comparisons were made between the predicted ankle ligamentous injuries based on radiographic Lauge-Hansen classifications, preoperative MRI analyses, and intraoperative findings. Results: On the basis of the Lauge-Hansen system and injury radiographs, 77% (231/300) were classified as supination external rotation, 13% (40/300) were pronation external rotation, 4% (11/300) were supination adduction, <1% (1/300) was pronation abduction, and 6% (17/300) were not classifiable. Of the 283 fractures that were classified into Lauge-Hansen classes, 266 (94%) had MRI readings of ligamentous injuries consistent with the Lauge-Hansen predictions. Intraoperative findings also highly correlated with the Lauge-Hansen class of ankle fractures, with nearly complete agreement. Comparing MRI and intraoperative findings revealed discrepancies in 6% (16/283) of ankle fracture classifications. Conclusions: In our large cohort of patients, comparisons between injury radiographs, preoperative MRI, and intraoperative findings suggest that the Lauge-Hansen system is an accurate predictor of ligamentous injuries. The predictions based on the Lauge-Hansen system can be useful for fracture reduction maneuvers and operative planning. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation

BackgroundCompartment syndrome is an elevation of intracompartmental pressure to a level that impairs circulation. While the most common etiology is trauma, other less common etiologies such as burns, emboli, and iatrogenic injuries can be equally troublesome and challenging to diagnose. The sequelae of a delayed diagnosis of compartment syndrome may be devastating. All care providers must understand the etiologies, high-risk situation, and the urgency of intervention.Questions/PurposesThis study was conducted to perform a comprehensive review of compartment syndrome discussing etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention.MethodsA literature search was performed using the PubMed Database and the following search terms: “Compartment syndrome AND Extremity,” “Compartment syndrome AND Gluteal,” and Compartment syndrome AND Paraspinal.” A total of 2,068 articles were identified. Filters allowed for the exclusion of studies not printed in English (359) and those focusing on exertional compartment syndrome (84), leaving a total of 1,625 articles available for review.ResultsThe literature provides details regarding the etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention. The development and progression of compartment syndrome is multifactorial, and as complexity of care increases, the opportunity for the syndrome to be missed is increased. Recent changes in the structure of in-hospital medical care including resident work hour restrictions and the incorporation of midlevel providers have increased the frequency of “signouts” or “patient handoffs” which present opportunities for the syndrome to be mismanaged.ConclusionThe changing dynamics of the health care team have prompted the need for a more explicit algorithm for managing patients at risk for compartment syndrome to ensure appropriate conveyance of information among team members.