R. Dale Blasier

Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications.

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.

Intravenous Regional Anesthesia: A Safe and Cost-Effective Outpatient Anesthetic for Upper Extremity Fracture Treatment in Children

We reviewed our most recent 100 consecutive cases with respect to efficacy and safety of anesthesia in which Bier block anesthesia was used to reduce upper extremity fractures. Records were reviewed to document diagnosis, number of reduction attempts, efficacy of anesthesia, and incidence of complications and untoward effects. No adverse effects were noted from lidocaine injection or tourniquet release. The cost of Bier block anesthesia administered in the emergency room (ER) was significantly less than that of a general anesthetic in the operating room. We have found the Bier block to be a safe, reliable, and cost-effective anesthetic in treatment of childrens upper extremity fractures in the ER.

Comparison of radiolucent and fracture tables in the treatment of slipped capital femoral epiphysis.

Abstract: A retrospective study was undertaken to see whether there was any difference in the time required and the accuracy of pin placement between slips pinned on a fracture table and those pinned on a radiolucent table. All patients were treated by single screw fixation of stable slipped capital femoral epiphysis (SCFE), 36 on a fracture table and 29 on a radiolucent table. Mean operating room time on the fracture table (63 minutes) was greater than that on the radiolucent table (51.2 minutes) (P < 0.05). Mean surgery time for the fracture table (38.55 minutes) was greater than that on the radiolucent table (24.8 minutes) (P < 0.05). The deviation of screw placement from the ideal for the two tables was not significantly different in the anteroposterior or lateral planes. The use of the radiolucent table, with manipulation of the limb to obtain lateral images of the hip, is a useful alternative to use of the fracture table for pinning of SCFE.

Acquired spondylolysis after posterolateral spinal fusion.

A case of spondylolysis occurring immediately above a posterolateral lumbar spinal fusion in a 12-year-old girl is described. This case illustrates a potential problem of stress concentration at the pars interarticularis, previously only described after posterior interlaminar fusion.

Opinion survey regarding pediatric orthopaedic trauma call and emergency trauma management.

Background: To determine the attitudes and practices of pediatric orthopaedic surgeons regarding on-call coverage and emergency fracture management. Methods: A 32-question online survey was sent to all 597 active members of the Pediatric Orthopaedic Society of North America. There were 296 completed surveys, for a response rate of 49.6%. Results: Of the respondents, 85.1% were male. The respondents ranged in age from 30 to older than 70 years, with 54% between 36and 50 years of age, corresponding to an average of 15 years in practice. Seventy-seven percent of the respondents felt that taking trauma call is an integral aspect of being a pediatric orthopaedist. Of the respondents, 64.9% take call 1 to 9 times per month, 15.8% take 10 to 19 calls, 2.7% take 20 or more, and 16.6% take no call. The number of orthopaedists taking call per practice was fairly evenly distributed between 3 and 10. Call was shared equally in 32% of practices, and mandatory in 72%. Twenty-eight percent of the respondents were additionally compensated for taking calls, in amounts ranging from

Direct Reduction with Indirect Fixation of Distal Tibial Physeal Fractures: A Report of a Technique

100 to

Traumatic Dislocation of the Hip in a High School Football Player

2000 per night, with 1000 dollars the most common rate. One third of operative cases are done that night; one third, the next day; and one third, later in the week. Twenty-four percent of the respondents have dedicated operative block time on the day after the call. Forty-seven percent have a dedicated fracture clinic, of which 51% receive institutional support. Conclusions: Providing emergency trauma care for children is an integral aspect of pediatric orthopaedics. This survey provides information on the attitudes and strategies of practicing pediatric orthopaedic surgeons in the face of decreasing manpower and increasing demand for such services.

External fixation of pediatric femur fractures: Indications and technique for successful results

Displaced intraarticular fractures of the distal tibia in children often require open reduction and internal fixation. Displaced epiphyseal fractures in the sagittal plane may be difficult directly to visualize from a standard medial malleolar incision, so accurate reduction may be impossible. Approaching the ankle joint by anterior arthrotomy, the fracture line can be directly visualized and accurately manipulated and reduced. However, access to the medial malleolus for insertion of internal fixation devices may be difficult from an anterior incision. We have found that after anterior arthrotomy and open reduction, rigid fixation can be placed percutaneously from medially or, in exceptional cases, from laterally under fluoroscopic control. The physis and talocrural joint can be seen and avoided in the growing child. Thirteen cases fixed by this method are reported. At 12.2-month average follow-up, clinical results were excellent. There were no instances of joint degenerative changes but one growth derangement.

Closed intramedullary rodding of pediatric adolescent forearm fractures

Background: Although traumatic dislocation of the hip often occurs as a result of automobile accidents, dislocations have been reported to occur during sports activities. Objective: Using the experience in treating a 17-year-old high school football player with a posterior dislocation, complicated by involvement of the sciatic nerve, this case report provides background information on hip dislocations and provides a description of the immediate treatment by the physician, followed by 6 weeks of immobilization, and a detailed account of the 5-month intervention. Case Description: The patient was injured while making a tackle during a high school football game when another player fell on him from behind. The case report describes his plan of care after immediate hip reduction surgery and 6 weeks on crutches. Generally, the program utilized a progression of non–weight-bearing resistance training and stretching in the initial stages of intervention and progressed to weight-bearing activities (on land and in the pool) as the patient was able to tolerate more stress. In addition, the treatment of the sciatic nerve using electrical stimulation during treadmill walking is described. Outcomes: The patient was seen in an outpatient physical therapy clinic an average of 2 times per week for 5 months. At the end of 5 months, results of the Lower Extremity Functional Scale (LEFS) indicated that recreational and sporting activities were within normal limits, and the patient was able to return to playing on his high school football team the next year.

Gartland Type-II Supracondylar Humeral Fractures in Children

Abstract External fixation of pediatric femur fractures has been successfully used by the authors for the past 10years. The method involves careful attention to technical detail in this select group of patients. Children between the ages of 6 and 10 years who are attending school with both parents working seem to benefit most from this procedure. A modular monolateral external fixation frame using four half-pins is preferred. The most proximal and distal pins are placed first for reduction of the fracture in rotation, length, and varus-valgus. The central two pins are added for reduction of flexion and extension. Manual reduction is accomplished on a radiolucent table using a C-arm.A short hospitalization allows for teaching the caregivers pin care techniques and encouraging the patient to be ambulatory.Monthly clinic visits are also helpful to treat the 1 in 10 patients with pin tract inflammation. Fixator removal is accomplished at 12 weeks under outpatient anesthesia to allow for knee manipulation and debridement of the pin tracts at 12 weeks.Overgrowth has been insignificant at an average of 6 to 8 mm, with a maximum of 10 mm in only one third of the patients. Potential complications of spica cast treatment, including compartment syndrome and skin necrosis, are avoided. The children are active with their peers, ambulatory, and attend school while both parents are able to work. Several important technical aspects of the procedure are described in the following article.