Neil E. Green

Stress and coping with scoliosis: psychological effects on adolescents and their families

The psychological, functional, and family impact of brace treatment for idiopathic scoliosis was assessed in a cross-sectional follow-up study. Eighty-four percent of parents described the initial bracing period in stressful terms. Establishing a daily routine facilitated coping with bracewear treatment. While bracewear did not necessarily affect participation in many common activities, subjects perceived limitations in sports, physical activities, and social events. There was no evidence of overt psychopathology among the subjects, although the initial bracewear period was associated with lower levels of self-esteem. Recommendations that can minimize the stresses attendant to bracewear treatment are given.

Ketamine sedation for the reduction of children's fractures in the emergency department.

Background: There recently has been a resurgence in the utilization of ketamine, a unique anesthetic, for emergency-department procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of childrens fractures in the emergency department. Methods: One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the emergency department at a level-I trauma center were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic, and the patients were monitored by a registered nurse. Any pain during the reduction was rated by the orthopaedic surgeon treating the patient according to the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS). Results: The average time from intravenous administration of ketamine to manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes), and the average time from intramuscular administration to manipulation was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). The average score according to the Childrens Hospital of Eastern Ontario Pain Scale was 6.4 points (range, 5 to 10 points), reflecting minimal or no pain during fracture reduction. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Patency of the airway and independent respiration were maintained in all of the patients. Blood pressure and heart rate remained stable. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphoric reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares. Conclusions: Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of childrens fractures in the emergency department at our institution. Ketamine should only be used in an environment such as the emergency department, where proper one-on-one monitoring is used and board-certified physicians skilled in airway management are directly involved in the care of the patient.

Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children

Summary: A retrospective review of 101 supracondylar humerus fractures in children between the ages of 0 and 11 years identified 15 patients with neural lesions. All were associated with displaced fractures, and 10 (66%) required open reduction for definitive fracture management. Six of these lesions were isolated anterior interosseous nerve palsies and four other patients had an anterior interosseous nerve injury in combination with another nerve injury, producing a sensory deficit. Two patients had a complete median nerve palsy. Only three patients had nerve lesions that did not involve the anterior interosseous nerve. The incidence (15%) of neural lesions in this study is similar to that reported elsewhere, but the incidence of anterior interosseous nerve lesions, particularly those occurring as an isolated injury, is much higher than has been reported previously. Because an anterior interosseous nerve palsy results in motor loss only, this injury may be easily overlooked.

Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children.

Summary A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18–80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263–272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15° of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.

Open reduction and internal fixation of pediatric forearm fractures.

Twenty-six skeletally immature patients with 27 displaced, diaphyseal forearm fractures treated by open reduction and internal fixation were reviewed. The mean age of the patients at the time of injury was 11.5 years (range, 4-15). Indications for surgery included open fractures (10), unacceptable closed reduction (14), and loss of reduction (three). Anatomic or near anatomic fixation was achieved with either compression plates or intramedullary wires. The average time to union was 3.5 months. The average length of follow-up was 39 months (range, 9-98). All but three patients regained full range of motion equal to that of the uninjured extremity. Three complications occurred, including one deep infection resulting in delayed union, one nonunion with failure of hardware, and one proximal radioulnar cross-union. We conclude that open reduction and internal fixation is indicated and can be safely performed in children with open or unstable or both-bone forearm fractures when closed treatment methods have failed. Fixation is reliably achieved with compression plating or intramedullary nailing.

Brace-wear compliance in patients with adolescent idiopathic scoliosis.

Thirty-eight full-time and 38 part-time unselected brace wearers treated during a 7-year period were interviewed in a retrospective study to determine actual brace-wear compliance. Actual compliance was found to be lower than reported by patients during clinic visits and was much lower than reported in previous series. Only 15% of patients were highly compliant. On average, patients wore their braces 65% of the time they were instructed to do so. The reasons for low compliance in brace wear are unclear.

Anesthesia and analgesia for the ambulatory management of fractures in children.

The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). Important factors in choosing a particular technique include ease of administration, efficacy, safety, cost, and patient and parent acceptance. Local and regional techniques, such as hematoma, axillary, and intravenous regional blocks, are particularly effective for upper-extremity fractures. Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.

Split posterior tibial-tendon transfer in spastic cerebral palsy.

Sixteen split posterior tibial-tendon transfers, usually with heel-cord lengthening, were performed on sixteen children with spastic cerebral palsy and equinovarus deformities. The patients were followed for a minimum of two years postoperatively. All of the varus deformities were corrected, although two patients required an osteotomy of the calcaneus because of fixed varus deformity. There were no recurrences of the varus deformities, nor were any valgus or calcaneal deformities produced, and the equinus element of the gait was eliminated.

The Catalytic Mechanism of Endoplasmic Reticulum Signal Peptidase Appears to Be Distinct from Most Eubacterial Signal Peptidases

Many type I signal peptidases from eubacterial cells appear to contain a serine/lysine catalytic dyad. In contrast, our data show that the signal peptidase complex from the endoplasmic reticulum lacks an apparent catalytic lysine. Instead, a serine, histidine, and two aspartic acids are important for signal peptidase activity by the Sec11p subunit of the yeast signal peptidase complex. Amino acids critical to the eubacterial signal peptidases and Sec11p are, however, positioned similarly along their primary sequences, suggesting the presence of a common structural element(s) near the catalytic sites of these enzymes.

Decline of Bone and Joint Infections Attributable to Haemophilus Influenzae Type b

Haemophilus influenzae has been a major cause of infectious diseases in children and has been attributed as a significant cause of septic arthritis and osteomyelitis in children. With the advent of widespread vaccination, the incidence of Haemophilus influenzae meningitis and other infections has been well documented. This is thought to be the first report that documents the effect of vaccination on bone and joint infections. One hundred sixty-five cases of acute hematogenous osteomyelitis or septic arthritis treated at the Department of Orthopaedics at Vanderbilt University in the years before and after the advent of the Haemophilus influenzae vaccine to assess whether vaccination affected the incidence of these diseases. The data indicate that the Haemophilus influenzae vaccine has reduced to near 0 the incidence of bone and joint infections because of Haemophilus influenzae. These findings suggest that coverage of Haemophilus influenzae as part of the empiric antibiotic coverage may be no longer needed in the management of acute hematogenous osteomyelitis and septic arthritis in children.