Richard A. K. Reynolds

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.

Variability in gait analysis interpretation.

The purpose of this study was to assess the reliability of interpretation of gait analysis data between physicians and institutions. Gait analysis data from seven patients were reviewed by 12 experienced gait laboratory physicians from six institutions. Reviewers identified problems and made treatment recommendations based on the data provided. Agreement among physicians for the most commonly diagnosed problems was slight to moderate (kappa range, 0.14–0.46). Physicians agreed on identification of soft tissue more than bony problems (intraclass correlation, 0.56 vs. 0.37). Variability regarding surgical recommendations for soft-tissue procedures (kappa range, 0.20–0.64) was similar to that for diagnosis of both soft-tissue and bone problems, although recommendation for hamstring lengthening showed substantial agreement (kappa = 0.64). There was less agreement in recommendation of osteotomies (kappa range, 0.13–0.22). Physicians agreed more on the number of soft-tissue procedures than bone procedures recommended (intraclass correlation, 0.65 vs. 0.19). There was an interinstitutional difference in the frequency of soft-tissue (p = 0.0152) and osseous problem identification (p = 0.0002), as well as in the frequency of recommendations for soft-tissue surgery (p = 0.0004) and osteotomies (p < 0.0001). Although gait analysis data are themselves objective, this study demonstrates some subjectivity in their interpretation. The interobserver variability reported here is similar to that reported for established classification systems of various orthopedic conditions.

Outcome of hamstring lengthening and distal rectus femoris transfer surgery.

To evaluate the outcome of hamstring lengthening and distal rectus femoris transfer, a retrospective study was performed comparing preoperative and postoperative gait analysis data from 16 children with neurologic involvement. Postoperatively, the timing of peak knee flexion during swing and the total arc of knee motion significantly improved. Hamstring range of motion and knee extension at terminal swing significantly improved, but stride length and gait velocity did not for the overall population. Patients who used braces postoperatively showed an improvement in stride length and velocity when wearing orthoses. This suggests that postoperative bracing may be needed in some patients to maximize the surgical outcome.

A technique to determine proper pin placement of crossed pins in supracondylar fractures of the elbow

Supracondylar humerus fractures are the most common elbow injury in children. Stable fractures can be closed, reduced, and casted, whereas unstable fractures require percutaneous pinning. Studies have shown that there is a biomechanical advantage of crossed pin fixation as opposed to two lateral pin fixation. However, medial pin placement has the risk of injuring the ulnar nerve. This modification of technique was used on 46 patients, aged 12 months to 14 years (median age, 3.6 years). Two patients had an ulnar sensory and motor neurapraxia, and two patients had cubitus varus deformities postoperatively. Thus, a safe, easy, and reproducible technique of crossed pin fixation is described here.

The Delay in Diagnosis of Slipped Capital Femoral Epiphysis: A Review of 102 Patients

ObjectivesThe aim of this study were (1) to evaluate the incidence of apparent missed diagnosis of slipped capital femoral epiphysis (SCFE) by the primary care system and (2) to identify possible factors leading to a delay in diagnosis of this disorder.Setting and DesignA retrospective review of emergency department records, outside medical charts, and preoperative and postoperative radiographs of children treated surgically for SCFE at the Children’s Hospital of Los Angeles (CHLA) from 1989 to 1997 was done to assess the delay in diagnosis for SCFE. The primary care system included outside emergency department visits, urgent care clinic visits, and private office visits.ResultsOf 102 patients (69 men, 33 women; mean age at surgery, 11.9 years), 68% were above the 95th percentile mean weight for age. Pain in the hip and/or groin was documented in 60%. The mean duration of symptoms experienced before being seen at CHLA was 140 days (hours to 1.5 years) and the mean delay after the first primary care visit till being seen at CHLA was 76 days (hours to 1 year). Fifty-two percent of primary care visits for hip, groin, knee, or thigh pain in obese children did not lead to either a diagnosis of SCFE or a referral for orthopedic evaluation.ConclusionsThis study documents a 2 1/2-month delay and a 52% incidence of apparent missed diagnosis for SCFE by the primary care system. There seems to be a need for increased orthopedic education for primary care providers.

Biomechanical analysis of compression screw fixation versus standard in situ pinning in slipped capital femoral epiphysis.

A slipped capital femoral epiphysis was created in 12 matched pairs of immature bovine femora using an anterior-to-posterior–directed shear force. All soft tissues, with the exception of the perichondrial ring, were removed before testing. One specimen from each pair was fixed with a single cannulated screw in standard fashion, whereas the contralateral specimen was fixed with a single screw that compressed the physis. The amount of compression achieved was quantified using Fuji film. Standard fixation yielded 1.4 MPa of pressure across the physis; compression fixation yielded 3.2 MPa, a 2.3-fold difference (p = 0.0001). The compression fixation was 47% more stiff than standard technique (p = 0.030), yet the differences in ultimate strength (p = 0.180) and energy absorbed at failure (p = 0.910) were not statistically significant. The stiffness of the compressed specimens remained less than that of the intact femora. Single-screw compression fixation of in vitro bovine femora was significantly more stiff than the current, widely used noncompression fixation technique, yet does not compromise the ultimate strength, energy absorbed, or the technical ease of single-implant fixation.

Variability in measurement of acetabular index in normal and dysplastic hips, before and after reduction.

This study examined the variability in the measurement of the acetabular index (AI) in normal and dysplastic hips, both before and after reduction. This variability for dysplastic hips is greater than that of normal hips. The variability is greater before an open or closed reduction than after reduction, and the variability after an open reduction is nearly 3 times greater than after a closed reduction. The 95% confidence interval of the AI is 10.1 degrees intraobserver and 21.9 degrees interobserver for all hips. The AI is most accurate in the situation in which it is most useful, after a closed reduction of a dysplastic hip. A 95% confidence interval of 5.1 degrees in this selected population supports the use of the AI for monitoring acetabular remodeling after closed reductions in accordance with previous clinical recommendations.

Psoas Over the Brim Lengthenings: Anatomic Investigation and Surgical Technique

Lengthening of the psoas tendon commonly is performed for various conditions of the hip including developmental dysplasia and neuromuscular contractures and instability. Anecdotal reports of injury to surrounding neurovascular structures suggest an investigation of the local anatomy is warranted. Using magnetic resonance images from 54 children younger than 10 years, the authors examined the anatomic relationship between major neurovascular structures (femoral artery and vein, external iliac artery and vein, femoral nerve) and the psoas tendon. The mean distance between the neurovascular structures and the psoas tendon in the over the brim position is 1 cm, although it may be as close as 4 mm in a child. The mean distance is 3.1 cm at the tendons insertion at the lesser trochanter. Surgeons performing psoas over the brim lengthenings should be aware that major neurovascular structures may be only 4 mm from the psoas tendon. The recommended surgical technique is presented.

Lymphangiomatosis of the spine: two cases requiring surgical intervention.

Study Design. Two cases of lymphangiomatosis of the spine are presented. Objectives. To report two cases of lymphangiomatosis of the spine requiring surgical intervention and to review the literature. Summary of Background Information. Lymphangiomatosis is a rare childhood disease characterized by abnormal lymph tissue at multiple sites. Skeletal and visceral involvement are both common. Prognosis depends on the extent of extraskeletal disease. Methods. Two cases of lymphangiomatosis causing neural compression and instability at the cervicothoracic junction are presented. Both patients underwent surgical decompression and stabilization. Results. One patient died, whereas the other regained full function and activity. Conclusions. Surgery is indicated when lymphangiomatosis causes neural compression and instability of the spine. Surgical outcome is strongly influenced by extraskeletal involvement.

Ultrasound Evaluation of Ulnar Nerve Anatomy in the Pediatric Population

Background: Ulnar nerve instability has been reported in up to 17% of children. Accurate assessment is important to achieve because of potential nerve complications that can arise from treatment of common pediatric fractures, including supracondylar humerus fractures. The objective of our study was to evaluate our ability to use ultrasonography to determine the extent of ulnar nerve dislocation in the normal pediatric population and to determine if there is a relationship between ulnar nerve instability and ligamentous laxity. Methods: We conducted a prospective ultrasound evaluation of 51 children, examining the excursion of the ulnar nerve through full range of motion. On the basis of its movement during flexion, the ulnar nerve was categorized as stable, subluxating, or dislocating. In addition, we assessed all subjects for ligamentous laxity using the Wynne-Davies signs of joint laxity. The subjects were then divided into groups based on age or ligamentous laxity, and statistical analysis was performed. Results: Most of the elbows evaluated had stable ulnar nerves (64/102, 62.7%), 27.5% (28/102) had subluxating nerves, and 9.8% (10/102) had dislocating nerves. Patients aged between 6 and 10 showed the highest rate of dislocating or subluxating nerves, with 50%, and also the highest average laxity score, 2.0. When grouped according to ligamentous laxity, patients who had multiple signs of ligamentous laxity had statistically higher numbers of subluxating and dislocating nerves (91.6%, 11/12) than those with lower laxity scores (25.6%, 10/39). Conclusions: There are a substantial number of subluxating or dislocating ulnar nerves in children, and the incidence is often bilateral. Patients with ligamentous laxity are more likely to possess unstable ulnar nerves. Ultrasound evaluation and assessment of ligamentous laxity are additional tools that can be used to assess elbow anatomy and identify children at risk for iatrogenic nerve injury. Level of Evidence: Level III, diagnostic study.