Robert B. Carrigan

18-month outcomes of heterologous bilateral hand transplantation in a child: a case report

BACKGROUND Although heterologous vascular composite allotransplantation has become a burgeoning treatment option for adult amputees, there have been no successful cases previously reported in children. Here, we describe the surgical, immunological, and neurorehabilitation details with functional outcomes 18 months after heterologous bilateral hand and forearm transplantation in an 8-year-old child with quadrimembral amputations and a previous kidney transplant. METHODS 2 years of extensive preparation by medical and surgical teams preceded the hand-forearm transplantation of this child. The initial immunosuppressive protocol included thymoglobulin, tacrolimus, prednisone, and mycophenolate mofetil. In July, 2015, our vascularised composite allotransplantation team did the first bilateral hand and forearm transplantation in a child, an 8-year-old boy with previous living-related kidney transplantation. The surgery included four teams working simultaneously on the donor and recipient limbs, aided by customised cutting guides that aimed to reduce ischaemia time. Following an extended length of time in hospital, skin biopsies and close monitoring of renal function and drug concentrations occurred weekly for the first 3 months and were slowly tapered to monthly, and then quarterly. Skin biopsies were also done when tissue rejection was suspected. Paediatric-specific rehabilitation techniques were applied to promote patient engagement during rehabilitation. Progress was assessed by monthly sensory and motor function tests during routine clinic visits and with serial functional brain imaging studies, including structural brain MRI, magnetoencephalography and transcranial magnetic stimulation. FINDINGS The surgery lasted 10 h and 40 min. Vascular revision of the ulnar artery was required a few hours postoperatively. There were no further immediate postsurgical complications. Rejection episodes occurred throughout the first year but were reversed. An increase in serum creatinine led to the addition of sirolimus at 3 months after transplantation with concomitant reduction in tacrolimus targets. Sensibility to light touch was present by 6 months after transplantation. Intrinsic hand muscle innervation was present by 7-10 months after transplantation. At 18 months, the child had exceeded his previous adapted abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet, and dress himself more independently and efficiently than he could do before transplantation. He remains on four immunosuppressive medications and functional neuroimaging studies have shown motor and somatosensory cortical reorganisation. INTERPRETATION Hand transplantation in a child can be surgically, medically, and functionally successful under carefully considered circumstances. Long-term data on the functional trajectory, neurological recovery, psychological sequelae, and the potential late effect of immunosuppression are still needed to support broader implementation of paediatric vascular composite allotransplantation. FUNDING The Childrens Hospital of Philadelphia.

Musculoskeletal Injuries Resulting from Use of Hoverboards: Safety Concerns With an Unregulated Consumer Product

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children’s hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.

Open Reduction and Internal Fixation of Radial Head Fractures

INTRODUCTION Treatment of radial head fractures remains a controversial topic. Treatment options have varied through the years, from early excision to nonoperative treatment. Recently there has been a movement in radial head preservation for reasons of forearm and elbow stability. In this paper we review the current indications as well as surgical technique of radial head fractures. Open reduction and internal fixation remains the treatment of choice of displaced fractures of the radial head.

The Diagnostic Utility and Clinical Implications of Wrist MRI in the Pediatric Population

Background: Unexplained wrist pain is a common presentation in children. To our knowledge, no studies have explored the clinical utility of magnetic resonance imaging (MRI) in the diagnostic workup of pediatric patients. Methods: We retrospectively reviewed 307 consecutive wrist MRIs ordered at a tertiary-care pediatric hospital. Demographic data and the indication for imaging were recorded and grouped into admitting categories. The final impression of each MRI was scored with regard to potential impact on future treatment (0 = normal, 1 = minimal, 2 = moderate, 3 = high). Patients who went on to wrist surgery within 1 year were noted. Results: In our cohort, 27% of all studies were normal, including 34% of those with pain. Although pain was the most common category, MRI was most useful in the delineation of a mass/cyst, evaluating for infection and evaluating arthropathy. Compared with all other categories, patients with pain were 3.6 times more likely to have a normal study and 4.6 times more likely to have a clinical score less than or equal to 1. Given an admitting diagnosis of pain, females were 1.7 times more likely to present for an MRI and 2.4 times more likely to have a normal MRI. The Spearman correlation revealed no linear relationship between age and MRI outcome. In all, 13% of patients went on to have surgery within 1 year of MRI. Conclusions: At our pediatric institution, the majority of wrist MRIs were ordered for wrist pain. Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis.

Osteomyelitis as a Late Complication of Percutaneous Pinning of a Supracondylar Fracture of the Distal Part of the Humerus

Case: We report a case of an eleven‐year‐old boy who presented to our clinic with a draining wound from the left elbow. He had a history of a left closed supracondylar humeral fracture that had been treated with closed reduction and percutaneous pinning at five years of age, and he subsequently developed late‐onset osteomyelitis. The patient was successfully treated with surgical irrigation and debridement, followed by intravenous and oral antibiotics. Conclusion: Dormant osteomyelitis should be considered in the differential diagnosis for any child who presents with elbow symptoms with a prior history of a supracondylar humeral fracture that has been treated with closed reduction and percutaneous pinning.