Paul D. Choi

Supracondylar Humeral Fractures in Children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children.

Background The aims of this study were to determine how often fracture reduction alone restored pulses and vascular perfusion in displaced supracondylar humerus fractures with absent distal pulses on presentation, and whether any preoperative factors were associated with the need for vascular repair and vascular complications. Methods We reviewed 1255 supracondylar humerus fractures in children treated operatively over 12 years at one institution. We identified 33 patients who presented with displaced supracondylar humerus fractures and absent distal pulses. We reviewed the management and outcome of these injuries. Results Thirty-three (of 1255) patients presented with a pulseless supracondylar humerus fracture (2.6%). The patients were divided into 2 groups: those at presentation whose hand was well perfused (n=24) or poorly perfused (9). None (0 of 24) of the well-perfused patients underwent vascular repair; 3 had open reduction. Of the 21 well-perfused patients undergoing closed reduction and pinning, 11 (of 21) had a palpable pulse after surgery and 10 (of 21) remained pulseless but well perfused; all did well clinically. Of the 9 patients in the poorly perfused group, 4 underwent vascular repair, and compartment syndrome developed in 2 during the postoperative period. In just over half of patients with a poorly perfused hand (5 of 9), fracture reduction alone was the definitive treatment. Conclusions In the largest series of children with pulseless displaced supracondylar humerus fractures in the literature, we identify 2 distinct populations, with the perfusion status of the hand at time of presentation correlating significantly with the ultimate need for vascular repair. In patients presenting with a well-perfused hand, fracture reduction alone was sufficient treatment in all 24 (of 24) cases, and no patients developed compartment syndrome. Nearly half of these patients still had an absent palpable pulse but well-perfused hand after closed reduction, yet did well clinically. Patients presenting with a poorly perfused hand are at high risk for vascular repair and compartment syndrome. Level of Evidence Therapeutic level IV. See Instructions to Authors for a complete description of levels of evidence.

How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children

Whereas operative treatment of supracondylar fractures is now standard of care for Gartland type 3 supracondylar humerus fractures in children, the treatment of type 2 fractures remains somewhat controversial. The purpose of this article was to examine the safety and efficacy of closed reduction and pinning of type 2 supracondylar humerus fractures in children. Methods: We performed a retrospective review of 189 type 2 supracondylar humerus fractures operatively treated at one tertiary care childrens hospital from 2000 to 2006. Data were acquired from a review of radiographs and clinical notes. Results: We found no intraoperative surgical or anesthetic complications in our series. None of our cases lost reduction after closed reduction and percutaneous pinning. There were 4 pin tract infections (2.1%) in our series: 3 were treated with antibiotics, and 1 needed irrigation and debridement in the operating room. This was the only patient who required reoperation for any reason. Conclusions: In this study, the largest reported series of type 2 supracondylar humerus fractures in children, we found an extremely low rate of complications after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%). Our series demonstrates a high probability of satisfactory outcome after operative treatment of type 2 supracondylar fractures compared with previous studies of children treated by closed reduction without pinning. Level of Evidence: Therapeutic study, level 4 (case series [no or historical control group]).

Efficacy of Intraoperative Neurologic Monitoring in Surgery Involving a Vertical Expandable Prosthetic Titanium Rib for Early-Onset Spinal Deformity

BACKGROUND The vertical expandable prosthetic titanium rib (VEPTR) device is used in the treatment of thoracic insufficiency syndrome and certain types of early-onset spinal deformity. The purpose of this study was to evaluate the risk of neurologic injury during surgical procedures involving use of the VEPTR and to determine the efficacy of intraoperative spinal cord neuromonitoring. METHODS Data were collected prospectively during a multicenter study. Surgical procedures were divided into three categories: primary device implantation, device exchange, and device lengthening. Further retrospective evaluation was undertaken in cases of neurologic injury or changes detected with neuromonitoring. RESULTS There were 1736 consecutive VEPTR procedures at six centers: 327 (in 299 patients) consisted of a primary device implantation, 224 were a device exchange, and 1185 were a device lengthening. Perioperative clinical neurologic injury was noted in eight (0.5%) of the 1736 cases: these injuries were identified after five (1.5%) of the 327 procedures for primary device implantation, three (1.3%) of the 224 device exchanges, and none of the 1185 device-lengthening procedures. Of the eight cases of neurologic injury, six involved the upper extremity and two involved the lower extremity. The neurologic deficit was temporary in seven patients and permanent in one patient, who had persistent neurogenic arm and hand pain. Intraoperative neuromonitoring demonstrated changes during six (0.3%) of the 1736 procedures: five (1.5%) of the 327 procedures for primary device implantation and one (0.08%) of the 1185 device-lengthening procedures. The surgery was altered in all six cases, with resolution of the monitoring changes in five cases and persistent signal changes and a neurologic deficit (upper-extremity brachial plexopathy) in one. Two patients had false-negative results of monitoring of somatosensory evoked potentials, and one had false-negative results of monitoring of somatosensory evoked potentials and motor evoked potentials during implant surgery; two had a brachial plexopathy and one had monoplegia postoperatively, with all three recovering. CONCLUSIONS Neurologic injury during VEPTR surgery occurs much more frequently in the upper extremities than in the lower extremities. The rates of potential neurologic injuries (neurologic injuries plus instances of changes detected by monitoring) during primary implantation of the VEPTR (2.8%) and during exchange of the VEPTR (1.3%) justify the use of intraoperative neuromonitoring of the upper and lower extremities during those procedures. As neuromonitoring did not demonstrate any changes in children without a previous VEPTR-related monitoring change and there were no neurologic injuries during more than 1000 VEPTR-lengthening procedures, intraoperative neuromonitoring may not be necessary during those procedures in children without a history of a neurologic deficit during VEPTR surgery.

Management of the Pulseless Pediatric Supracondylar Humeral Fracture

A pediatric supracondylar humeral fracture with a pulseless, poorly perfused hand requires emergency operative reduction. If the limb remains pulseless and poorly perfused after fracture fixation, vascular exploration and possible reconstruction is necessary. A pediatric supracondylar humeral fracture with a pulseless, well-perfused hand should be treated urgently with operative fixation of the fracture and subsequent reassessment of the vascular status. Controversy exists regarding the optimal management of pediatric supracondylar humeral fractures with a pulseless, well-perfused hand following anatomic reduction and fixation. Options include immediate vascular exploration or twenty-four to forty-eight hours of inpatient observation. If perfusion is compromised during this period of observation, an emergency return to the operating room for vascular exploration and possible reconstruction is indicated.

Radial neck fractures in children: experience from two level-1 trauma centers

The aim of this study was to compare different treatment modalities for different severities of pediatric radial neck fractures in a large cohort of patients and determine prognostic factors. A retrospective, comparative study was conducted of all children treated for different severities of radial neck fractures at two level-1 pediatric trauma centers between 1990 and 2007. Pertinent data were collected, and the outcome was measured by the Tibone criteria. Several variables were compared to determine the prognostic value. Seventy-eight children were identified, 35 male and 43 female, at an average age of 7.8 years (range 3–15 years). Twenty-nine of the 78 (37%) children had associated injuries. Fracture patterns varied in their severity. Nineteen patients needed casting alone; 16 required closed reduction; of the children requiring surgery, 26 responded to percutaneous reduction and 17 were severe enough to need open reduction. Complications occurred in 28/78 (36%) children, 24 of which were related to stiffness. Seventeen of the 19 (89%) fractures that were amenable to casting alone had excellent or good outcomes, as did 11/16 (69%) in the closed reduction group. Among children treated operatively, 19/26 (73%) patients who underwent percutaneous reduction had an excellent or good outcome. Only 6/17 (35%) of the severe cases who underwent open reduction had an excellent or good outcome. The treatment method, essentially dictated by the severity of the cases, did correlate with the outcome (P=0.001). Compared with more severe fractures that required operative treatment, patients treated nonoperatively had a higher rate of excellent to good outcome (P=0.018). In particular, patients who underwent percutaneous reduction alone had improved outcomes versus open reduction (P=0.008). The outcome was not related to the presence of an associated injury (P=0.302). Initial fracture severity, as graded by the Judet classification, correlated with the outcome (P=0.004). Furthermore, age also expressed significance, as patients younger than 10 years of age tended to do better than those above 10 years of age (P=0.025). Children with less severe radial neck fractures amenable to nonoperative treatment fare well. Operative treatment of these fractures, particularly in severe cases when an open (not percutaneous) reduction is needed, is associated with a higher risk of poor outcome. Children over 10 years of age, especially those with more severe initial angulation, tend to fare worse. The presence of associated injuries does not appear to increase the risk of a poor outcome after treatment. There is a high rate of complications (36%), stiffness being the most common (24). This large bi-center retrospective study from two level-1 pediatric trauma centers emphasizes that in severe cases of radial neck fractures, open treatment does not necessarily decrease the risk of a poor outcome.

Postoperative alopecia in children after orthopaedic surgery.

Background: To report the cases of postoperative alopecia encountered after orthopaedic surgery at a single-level I trauma pediatric hospital. Methods: We report on 3 children who developed postoperative alopecia after an orthopaedic surgery. The chart review included demographics and independent variables including age, ethnicity, weight, sex, presence of coexisting medical conditions, type and duration of surgery performed, examination findings at presentation and diagnosis of alopecia, and outcomes were recorded. Inpatient and outpatient clinic notes, operative reports, and recorded vital signs were also reviewed. Results: Three children (2 female, 1 male) were noted to develop postoperative alopecia. The average age at surgery was 13.7 years (range, 12 to 16). There was no significant past medical history, and 2 of 3 patients had obesity as a comorbidity. The type of surgery included: 2 proximal femoral osteotomies with proximal femoral osteoplasties and 1 wide resection of a congenital tibia pseudarthrosis with contralateral vascularized fibular grafting and internal fixation. Mean surgical duration was 5.9 hours (range, 4.4 to 7.1), and no intraoperative episodes of hypotension (<50 mm Hg) or hypothermia (T<35.9°C) occurred. The patients presented 2 to 3 weeks after surgery with hair loss localized over the posterior portion of the head. All patients were noted to have hair regrowth within 8 to 12 weeks, with 1 patient fully recovered and 2 patients continuing hair regrowth at most recent follow-up. Conclusions: Postoperative alopecia is an uncommon but usually self-limited complication that can occur in children undergoing orthopaedic surgery. Although rare, the treating physician should be aware of its occurrence and course, and appropriate padding of the head during surgery is advised. Level of Evidence: Level IV—retrospective case series.

Interobserver and intraobserver reliability of the modified waldenström classification system for staging of legg-calvé-perthes disease

BACKGROUND The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

Abduction bracing after Pavlik harness failure: an effective alternative to closed reduction and spica casting?

Background: Previous studies have reported that the use of abduction bracing after Pavlik harness failure in patients with developmental dysplasia of the hip (DDH) is often effective in achieving hip reduction. Methods: This is a retrospective study of consecutive patients with DDH at a single institution between 2006 and 2011. Patients in this study met all 4 inclusion criteria: (1) DDH, (2) a dislocated or dislocatable hip, (3) unsuccessful treatment with a Pavlik harness, and (4) subsequent treatment with abduction bracing. Exclusion criteria were dislocated hips associated with neurological, teratologic, syndromic, or other nonidiopathic conditions. Results: Seven hips met inclusion criteria. Mean age at Pavlik harness initiation was 2.1 months (range, 1 d to 6 mo) and patients spent an average of 1.2 months (range, 0.4 to 2.7 mo) in the harness. After ultrasound demonstrated a persistently dislocated hip, patients were transitioned to an abduction brace and spent an average of 1.3 months (range, 0.1 to 3 mo) in the brace. One hundred percent (7/7) of hips treated with an abduction orthosis failed to reduce and required further treatment; 4 with closed reduction and spica casting, and 3 with open reduction. Patients were followed for an average of 33.6 months (range, 10 to 60 mo), and all patients had stable hips at latest follow-up. Conclusions: In this series of 7 patients with developmentally dislocated hips who failed Pavlik harness treatment, subsequent abduction bracing provided no benefit, in contrast to previous studies. All patients who failed Pavlik harness treatment went on to require closed or open reduction of the hip. Abduction bracing may unnecessarily prolong the time to definitive treatment. Level of Evidence: Case series, level 4.

Measurement Variability in the Evaluation of the Proximal Junction in Distraction-based Growing Rods Patients.

Background: Proximal junctional kyphosis (PJK) is a known complication of spinal fusion and has been shown to occur in the setting of growing rod instrumentation. Previous studies have shown good reliability in measuring PJK in adolescent idiopathic scoliosis. Methods: Four pediatric orthopaedic spine surgeons measured the proximal junction in 10 patients with growing rod instrumentation using 2 methods. In method 1, measurements were made from the inferior endplate of the upper instrumented vertebrae (UIV) to the superior endplate of 1 level above the UIV. In method 2, measurements were made from the inferior endplate 2 levels below the UIV to the superior endplate 2 levels above the UIV. These measurements were repeated 1 week later. Results: Method 1 had an intraobserver variability of ±13.2 degrees and interobserver variability of ±21.6 degrees, whereas method 2 had an intraobserver variability of ±18.3 degrees and interobserver variability of ±20.7 degrees. Conclusions: Interobserver variability of PJK is >20 degrees. As PJK is commonly defined as >10 degrees of kyphosis above the UIV, measurement of PJK in patients with distraction-based growing rods on lateral radiographs has too much variability to be useful. Level of Evidence: Level III—diagnostic studies.