Richard M. Schwend

Management of pediatric femoral shaft fractures.

Abstract Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school‐age child and for patients with high‐energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and softtissue irritation caused by the ends of flexible nails.

Childhood scoliosis: clinical indications for magnetic resonance imaging.

We retrospectively reviewed the magnetic resonance imaging studies that had been made for ninety-five patients who had idiopathic scoliosis. We wished to determine if we could identify any criteria that should be met before these studies are performed. The study group included thirty-one male patients and sixty-four female patients. The average age at the time of the imaging study was thirteen years (range, one to twenty-eight years). The average curve was 41 degrees (range, 11 to 95 degrees). Fourteen patients were seen to have an intraspinal abnormality on the imaging study: twelve had a syrinx, one had a syrinx and an astrocytoma of the spinal cord, and one had dural ectasia. Five of the eight patients who were less than eleven years old and who had a left thoracic curve had an intraspinal abnormality on the imaging study, but this combination of factors did not indicate the need for operative intervention. Four of the intraspinal abnormalities in the fourteen patients necessitated neurosurgical intervention; if the criteria for obtaining the imaging study had been restricted to neck pain and headache--particularly with exertion--and neurological findings such as ataxia, weakness, and a cavus foot, these abnormalities would have been diagnosed.

Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus.

This study evaluated forearm compartment pressures in 29 children with supracondylar humerus fractures. Pressures were measured before and after reduction in the dorsal, superficial volar, and deep volar compartments at the proximal 1/6th and proximal 1/3rd forearm. Pressures in the deep volar compartment were significantly elevated compared with pressures in other compartments. There were also significantly higher pressures closer to the elbow within each compartment. Fracture reduction did not have a consistent immediate effect on pressures. The effect of elbow flexion on post-reduction pressures was also evaluated; flexion beyond 90° produced significant pressure elevation. We conclude that forearm pressures after supracondylar fracture are greatest in the deep volar compartment and closer to the fracture site. Pressures greater than 30 mm Hg may exist without clinical evidence of compartment syndrome. To avoid unnecessary elevation of pressures, elbows should not be immobilized in >90° of flexion after these injuries.

Evaluating children with fractures for child physical abuse

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Pedicle Screw Instrumentation for Adult Idiopathic Scoliosis : An Improvement Over Hook/Hybrid Fixation

Study Design. A matched cohort comparison of adult idiopathic scoliosis (AdIS) patients treated with all pedicle screw constructs compared to hook/hybrid constructs. Objective. To compare clinical and radiographic results of AdIS treatment using all pedicle screw constructs versus hook/hybrid constructs. Summary of Background Data. Pedicle screw instrumentation has demonstrated excellent clinical efficacy in the treatment of pediatric spinal deformity. No prior reports have compared the outcomes of pedicle screw only constructs to hook/hybrid constructs in the treatment of AdIS. Methods. We analyzed 34 consecutive patients undergoing posterior-only correction for AdIS, using pedicle screw instrumentation at minimum 2-year follow-up. Thirty-four matching patients (11 with anterior releases) were selected from a cohort of 58 patients treated with hook/hybrid constructs based on similar age, curve type, magnitude, and fusion levels. Results. Significantly greater curve correction was seen in the pedicle screw compared to the hook/hybrid group (56 vs. 40%, P < 0.01). Coronal and sagittal imbalance were equivalent between the groups (P = 0.91 and 0.23, respectively). Thoracic kyphosis (T5–T12) was maintained in the pedicle screw patients but significantly increased in the hybrid/hook patients over time (P < 0.05). Scoliosis Research Society outcome scores significantly improved in both groups. Blood loss was equivalent but operative time was longer in the hook/hybrid patients. No pedicle screw patients were revised for instrumentation complications with 1 lumbosacral nonunion revised at 5 years postoperative (3% revision rate). Eight of 58 patients among the hook/hybrid cohort underwent 9 revisions for instrumentation failure (n = 3) or nonunion (n = 6) (14% revision rate; P = 0.04). Conclusion. Pedicle screw correction of AdIS is safe and effective. Compared to hook/hybrid constructs, these patients displayed significantly improved correction of the major curve (even in the absence of anterior releases), maintenance of thoracic kyphosis, and a lower revision rate. Similar SRS scores and blood loss were noted. The hook/hybrid patients had significantly longer operative times. The use of BMP-2 in 7 patients and TLIF/ALIF also in 7 of the pedicle screw patients may have decreased the need for revision surgery up to the latest follow-up.

Predicting ulnar nerve location in pinning of supracondylar humerus fractures

Thirty-four consecutive patients with displaced supracondylar humerus fractures were treated with reduction and percutaneous pinning. The precise location of the ulnar nerve to the medial pin was determined by intraoperative nerve stimulation. In 22 of the 34 patients, the authors attempted to predict the location of the ulnar nerve by palpation and placing a mark on the skin. They also recorded the ability to feel the anatomic landmarks for pin fixation, including the medial epicondyle and ulnar nerve. The average distance from the medial pin to the predicted location was 9.3 mm, whereas the actual distance measured 7.6 mm, for a significant difference of 1.7 mm. Statistically, the authors could not accurately predict the location of the ulnar nerve prior to blind percutaneous crossed K-wire fixation of supracondylar humerus fractures. However, clinically they were fairly close in their prediction and documented safe insertion and distance from the nerve. Intraoperative nerve stimulation may assist in localizing the nerve prior to placement of the medial pin. Stimulation of the pin itself following insertion is another technique to ensure safe pin placement and decrease the risk of injury.

Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

How accurately do novice surgeons place thoracic pedicle screws with the free hand technique

Study Design. Cadaver study. Objective. To evaluate with direct observation the errors made when novice resident surgeons place thoracic pedicle screws. To determine how many specimens need to be instrumented to assure an improvement in accuracy to currently published levels. Summary of Background Data. Thoracic pedicle screw instrumentation has been shown to provide numerous benefits in spinal deformity surgery including 3 column fixation of the spinal elements, decreased need for thoracoplasty or anterior thoracic release and decreased operative time and blood loss. Methods. Three orthopaedic residents inexperienced in pedicle screw placement received an introductory teaching session. Intact thoracic vertebral body specimens were harvested from 15 cadaver spines. Each vertebral body was mounted on a clear Plexiglas frame with only the posterior surface anatomy visible to the surgeon. Each resident surgeon instrumented 5 thoracic spines verbalizing all perceived pedicle wall violations as they occurred. An observer recorded the accuracy of the gearshift probe, flexible probe, tap, and screw placement. Critically perforated screws were defined as a greater than 2 mm breach of the pedicle wall. Results. Two hundred ninety-seven pedicles in 149 intact vertebral body specimens were instrumented. Eighty-five (29%) screws were not fully within the pedicle. Sixty-three (74%) were noncritical violations and 22 (26%) were critical violations. There were 18 (21%) screw violations not perceived by the surgeon to be outside the pedicle. There was a decrease in the proportion of total screw violations by the third cadaver (P < 0.001) and in critical screw violations by the fourth cadaver (P = 0.01). Conclusion. Novice resident surgeons placing thoracic pedicle screws in cadavers were able to significantly improve by the fourth cadaver to accuracy levels documented in the literature. Surgeons in training shouldpractice these skills in the laboratory before proceeding to the operating room.

The pylon concept of pelvic anchorage for spinal instrumentation in the human cadaver.

Study Design. Human cadavera morphometric analysis of the iliac columns and biomechanical implant testing of traditional Galveston technique compared to intrailiac instrumentation of the entire iliac column. Objectives. To describe the anatomy of the iliac columns and to evaluate the strength in forward flexion of a large implant spanning the entire column length compared to standard Galveston technique. Summary of Background Data. We have observed substantial and straight columns of bone in the pelvis, connecting the acetabula to the sacrum, which may allow for improved spinopelvic instrumentation. Methods. Twenty adult cadaveric pelves were used. Each specimen was oriented in the computed tomography scanner to obtain a cross-section of the iliac columns, which begin from 2 cm caudal to the posterior iliac spines and end above the acetabula at the anterior inferior iliac spines. Two different instrumentation techniques were used. Standard Galveston pelvic fixation with paired 6.25-mm diameter rods extending 8 cm into the pelvis (Group 1) was compared to paired 8-mm diameter, 15-cm long custom implants, placed within the length of the entire iliac columns and connected to 6.25-mm spinal rods (Group 2). Both constructs had two rigid cross-links connecting the rods. Testing in forward flexion was performed for each construct with the MTS model 881 at 5 N/sec until failure occurred. Results. The rectangular shaped iliac columns averaged 15.2 (SD 0.8) cm in length, 2.5 (SD 0.3) cm in width and were consistently straight. The iliac column orientation as viewed in the transverse plane was 22° laterally directed from the midsagittal plane. For the Galveston technique, failure with a flexion force occurred at a mean of 682 (SD 217) N. The iliac column implants failed at a mean of 2153 (SD 1370) N (P < 0.004). Conclusion. The human adult pelvis has substantial and straight columns of bone extending from 2 cm below the posterior iliac spine, traversing above the sciatic notch, and ending at the anterior iliac spine. The shape resembles a weight-bearing long bone such as the tibia. Analogous to the architectural pylon, in this cadaver model, large implant instrumentation of the entire length of these pelvic columns provides at least three times stronger anchorage for spinal instrumentation compared to standard Galveston technique.

Screening the newborn for developmental dysplasia of the hip: Now what do we do?

The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. Although evaluation of children with risk factors for DDH is important, most DDH occurs in infants who have no risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised. Despite having had normal newborn and infant hip examinations, there remains the possibility of a late-onset hip dislocation needing treatment in approximately 1 in 5000 infants.