Maurice B. Albright

Multidetector computed tomography of pediatric lateral condylar fractures.

The objective of this study was to compare lateral condylar fracture characterization using radiographs and multidetector computed tomography (MDCT) of the elbow and to evaluate outcomes in a group of children managed based on MDCT findings. Methods: Unenhanced MDCT of the elbow with sagittal and coronal reformations was prospectively performed without sedation in 10 children between 1 and 16 years of age with lateral condylar fractures identified on frontal and lateral radiographs of the elbow. Two blinded readers reviewed all radiographs and MDCT images independently and in consensus. For the radiographs and MDCT images, readers graded the displacement of the lateral condyle fracture fragment and classified the fractures according to the Milch classification. Articular and epiphyseal cartilage integrity was assessed on MDCT. Patients were managed based on the consensus interpretation of the MDCT study. The frequency of interobserver agreement, discordant grading of fracture displacement and fracture classification between radiographs and MDCT images, and altered management based on the MDCT findings were determined. Results: Individual readers agreed on fracture displacement in 9 patients (90%) on radiographs and in all 10 patients (100%) on MDCT. Individual readers agreed on fracture classification in 4 patients (40%) on radiographs and in 9 patients (90%) on MDCT. In 4 patients (40%), grading of fracture displacement differed between the consensus interpretation of the radiographs and MDCT images. In 6 patients (60%), fracture classification differed between the consensus interpretation of the radiographs and MDCT images. All 3 patients with fracture displacement greater than 5 mm and 1 patient with fracture displacement between 2 and 5 mm demonstrated disruption of the articular and epiphyseal cartilage on MDCT. Two patients (20%) with fracture displacement near the surgical threshold of 2 mm had altered management based on the MDCT findings. All patients progressed to complete fracture healing, with no delayed displacement or other complications. Conclusions: Multidetector computed tomography is a highly reproducible means of characterizing pediatric lateral condylar fractures and frequently demonstrates disruption of the epiphyseal and articular cartilage in patients with fracture displacement greater than 2 mm. The findings of MDCT may lead to altered treatment in patients with fracture displacement near the surgical threshold of 2 mm.

Correction of non-Blount's angular knee deformity by permanent hemiepiphyseodesis.

This retrospective study evaluated the results of permanent hemiepiphyseodesis for the correction of non-Blount’s coronal plane angular knee deformity. The medical records and radiographs of 75 patients with 125 angular knee deformities were analyzed for overall rate of success and factors predicting successful correction of deformity. There were 38 patients with idiopathic genu valgum and 37 with various other skeletal disorders. Sixty-nine out of 75 patients had reached skeletal maturity at latest follow-up. One hundred six knees out of 125 were successfully treated by the procedure. Of the 19 remaining knees, 15 were operated on too close to skeletal maturity to expect correction and 4 were technically unsuccessful in achieving closure of the targeted physis. There were no complications other than overcorrection, which occurred in 15 knees (11 patients). This study indicates that permanent hemiepiphyseodesis is a very useful procedure if performed in a timely and technically successful manner.

The Newborn Foot: Diagnosis and Management of Common Conditions

An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allowing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipatory guidance to the parents.Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular disorders and syndromic conditions. Common newborn foot abnormalities include equinovarus deformity (clubfoot), metatarsus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamental nursing implications needed to care for these young patients and their families.

MDCT of the Elbow in Pediatric Patients with Posttraumatic Elbow Effusions

OBJECTIVE The purpose of this study was to determine the performance characteristics of MDCT in the detection of fractures in children with posttraumatic elbow effusions and to assess the effect of MDCT findings on clinical management. SUBJECTS AND METHODS Unenhanced MDCT of the elbow was prospectively performed without sedation on 31 children 20 months to 16 years old who had posttraumatic elbow effusions. Two blinded reviewers independently and in consensus characterized all MDCT scans as positive or negative for the presence of fracture. Level of interobserver agreement was determined with the kappa statistic. Sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for fracture detection were determined for the consensus MDCT interpretations with follow-up radiographs as the reference standard. Patients were treated with casts and instructed to return in 2-3 weeks for clinical and radiographic follow-up unless a change in management was indicated on the basis of MDCT findings. The frequency of alteration of management was determined. RESULTS Both reviewers detected fractures in 15 (48%) of the patients individually and in 16 (52%) of the patients by consensus. Interobserver agreement for fracture detection with MDCT was excellent (kappa = 0.85). The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in the detection of fractures were 92%, 79%, 79%, and 92%, respectively. Four (13%) of the children had changes in management based on the MDCT findings. CONCLUSION MDCT is a sensitive means of evaluating for radiographically occult fractures in children with posttraumatic elbow effusions. It has a high negative predictive value and a high level of interobserver agreement. MDCT findings may lead to alteration of treatment of children with nondisplaced lateral condylar and radial head fractures.

Discoid lateral meniscus in children.

The discoid lateral meniscus is the most common abnormal meniscal variant in children. It affects the shape and mobility of the menisci, altering the normal mechanical relationships between the articulating surfaces of the knee and predisposing it to injury. The incidence of discoid lateral meniscus is estimated to be 1%–3% in the pediatric population and the condition is bilateral in 10%–20% of patients (Stanitski, 2002). An otherwise asymptomatic knee with an incidentally detected discoid meniscus does not require surgical intervention. However, a discoid lateral meniscus is much more likely to tear, and many children develop pain as well as mechanical symptoms (popping, snapping, locking, or giving way of the knee). Recent improvements in arthroscopic technique have led to greater attempts to stabilize, sculpt, and repair the torn discoid lateral meniscus. This article will review the classification, clinical presentation, diagnostic/imaging studies, and treatment options for a discoid lateral meniscus in children.

Common pediatric elbow fractures.

Fractures of the elbow are a very common injury in children. The most common mechanism of injury is a fall on an outstretched upper extremity during play. Ranging in complexity from low-energy nondisplaced occult fractures to high-energy fractures with associated severe soft-tissue and neurovascular injuries, elbow fractures are a challenging problem for all pediatric healthcare providers. Because of the wide spectrum of fracture severity and associated bony and ligamentous injury, a very diverse spectrum of treatment modalities is necessary for optimal results. Management is based on fracture pattern, patient age and bone quality, extent of soft tissue damage, functional needs of the patient, and the presence of associated injuries. This article will give a brief overview of 4 common pediatric fractures, current treatment algorithms, and frequent complications associated with these injuries.

Broken bones: common pediatric lower extremity fractures--Part III.

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.

Discoid Lateral Meniscus: Anatomy and Treatment

ABSTRACT The discoid meniscus is an anatomic variation that more often involves the lateral meniscus. It affects the shape and mobility of the menisci, altering the normal mechanical relationships between the articulating surfaces of the knee and predisposing it to injury. An otherwise asymptomatic knee with an incidentally detected discoid meniscus does not require surgical intervention. Improvements in arthroscopic technique have led to greater attempts to stabilize, sculpt, and repair the torn discoid meniscus rather than opt for a complete meniscectomy. The midpatellar lateral portal described by the senior author has facilitated the understanding of the arthroscopic anatomy of the lateral compartment, especially the lateral meniscocapsular ligament and the popliteal tunnel and hiatus. It also prevents crowding and collision of the instruments during surgery on a discoid meniscus. In addition to imaging features and the operative technique, results of various studies are discussed. Recommendations to retain a stable peripheral rim of the discoid meniscus are based on these studies as well as the senior authors personal experience.

Broken bones: common pediatric fractures--part I

Musculoskeletal injuries are one of the most frequently encountered problems in pediatric practice, with fractures accounting for a surprisingly large percentage of these injuries. A fracture occurs when bone is subjected to more energy than it can absorb. Pediatric healthcare providers must have a good understanding of normal bone growth and development and must recognize common mechanisms of injury and fracture patterns seen in children. Nearly 20% of children who present with an injury have a fracture, and it is estimated that 42% of boys and 27% of girls will sustain a fracture during childhood (Wilkins, 1996). The immature skeleton has several unique properties that directly affect the management of fractures in children.

Developmental dysplasia of the hip: nursing implications and anticipatory guidance for parents.

Developmental dysplasia of the hip (DDH) is a comprehensive term used to describe an abnormal relationship between the femoral head and the acetabulum. Developmental dysplasia of the hip includes a very wide spectrum of abnormality from a frank dislocation (very unstable) to a stable hip with a slightly shallow acetabulum. As many of these findings may not be present at birth, the term developmental more accurately reflects the biologic features than does the term congenital. Despite the recent increased awareness of DDH and the importance of thorough screening programs, hip dysplasia continues to be a frequently missed diagnosis in pediatrics. Earlier detection and diagnosis of DDH is associated with a much more successful and less invasive outcome.