Susan L. Foad

Traumatic Anterior Shoulder Dislocation in Adolescents

Background Recurrent instability is the most common complication after traumatic anterior shoulder dislocation in young patients. Hypothesis The rate of recurrent instability in a homogeneous population of adolescents after initial traumatic anterior shoulder dislocation is significant and is associated with a guarded prognosis for full recovery. Study Design Retrospective cohort study. Methods We identified 32 patients 11 to 18 years of age treated at our institution for a radiographically documented traumatic anterior shoulder dislocation; we performed a functional outcome assessment on 30 patients with use of two standard scoring systems. Results Overall, instability recurred in 24 of 32 patients, with 23 experiencing at least one recurrent dislocation. Persistent instability led 16 of 32 to undergo a shoulder stabilization procedure. There were no significant differences in the functional outcome of patients who had undergone surgical stabilization and those who were treated nonoperatively. Conclusions The recurrence rate of shoulder instability was 75%. Outcome scores were similar for patients treated with a surgical procedure and those treated nonoperatively. Clinical Significance Treatment efforts must be aimed at optimizing shoulder strength and stability. Prognosis for full recovery remains guarded. Available outcome instruments may not discriminate well between patients who do and do not choose surgery.

Displaced type II extension supracondylar humerus fractures: do they all need pinning?

The treatment of a displaced type II extension supracondylar humerus fracture is controversial. Many authors recommend that all displaced type II fractures be surgically pinned. The purpose of this study was to determine the success of reduction and casting (without pinning) in maintaining the alignment of type II fractures. Of the 25 elbows that underwent an initial reduction in the emergency room, 18 (72%) maintained alignment. Seven fractures lost position, and five of the seven patients underwent secondary reduction and pinning. Twenty-three of the 25 (92%) elbows had a satisfactory outcome and 2 of the 25 (8%) had an unsatisfactory outcome according to the Flynn criteria. All 24 patients were satisfied with the treatment on a satisfaction survey. An attempt at closed reduction and casting, with selective pinning of the fractures that lose position, appears justified if close follow-up can be maintained.

Hematoma block reduces narcotic pain medication after femoral elastic nailing in children.

Children with femur fractures can have severe pain after elastic nail fixation. The purpose of this paper is to test the effectiveness of an intraoperative hematoma block in controlling postoperative pain in children that underwent elastic nail fixation of isolated femur fractures. We compared 13 children who received an intraoperative bupivacaine hematoma block after elastic nail fixation of a femur fracture with a concurrent control group of 22 children with similar femur fractures that did not receive a hematoma block. The time to first narcotic dose after surgery was over 5 hours later in the hematoma block group versus the control group (P = .008). The hematoma block did not significantly lengthen the time of surgery. This study demonstrates that an intra-operative hematoma block is a simple, quick and effective method of postoperative pain control after elastic femoral nailing in children.

The use of conscious sedation for pain control during forearm fracture reduction in children: does race matter?

Recent reports in the medical literature indicate that certain racial disparities have been identified in healthcare. The authors sought to identify the potential relationship between the use of pain medications in African-American and Caucasian children undergoing forearm fracture reduction. This retrospective cohort study was performed at a university-affiliated tertiary care childrens hospital emergency department. All Caucasian and African-American patients who underwent a closed reduction of a fractured ulna or radius over the 2-year observational period were enrolled. Patients were excluded from the study if they were admitted to the hospital for an open reduction or had multiple injuries. The relationship between race, gender, insurance status, time of admission, length of stay in the emergency department, fracture characteristics, and the use of conscious sedation was analyzed. t tests, chi-square tests, and stepwise logistic regression were used for data analysis. A total of 503 patients were included, 83% Caucasian and 17% African-American. Four hundred four patients received conscious sedation as part of their fracture reduction procedure and 99 did not. Univariate analysis showed that African-American and Caucasian children had different forearm fracture patterns (P = 0.0116) and different severities of angulation (P = 0.0094). Multivariate statistical analysis revealed that higher amounts of fracture translation (P < 0.0001) and angulation (P < 0.0027) and younger age of the patient (P = 0.0059) were significant predictors of conscious sedation use. Race was not found to be significantly associated with the use of conscious sedation (P = 0.0606 in univariate analysis, P = 0.1678 in multivariate analysis). The authors found that the decision to use conscious sedation for pediatric forearm fractures was not influenced by race, but was influenced by certain fracture characteristics and patient age.

EMG and MRI are Independently Related toShoulderExternal Rotation Function inNeonatalBrachial Plexus Palsy

Background Few studies exist with regard to the ability of electromyography (EMG) and volumetric magnetic resonance imaging (MRI) of the infraspinatus muscle to complement the physical assessment of active global shoulder external rotation (GER) in the neonatal brachial plexus palsy (NBPP) population. Therefore, the purpose of this study was to evaluate the relationships of EMG and MRI with active GER based on analysis of the infraspinatus muscle. Methods Seventy-four NBPP patients (mean age, 5 y 1 m; range, 1 y 1 m to 13 y 3 m) who had undergone physical examination of the shoulder, EMG evaluation of the infraspinatus muscle, and shoulder MRI were included in this study. The outcome variable active GER was dichotomized into <0 degree active GER (poor) and ≥0 degree active GER (good). The interference pattern on EMG of the infraspinatus muscle was graded on a 6-point scale and dichotomized into ⩽4 and ≥5. On shoulder MRI, infraspinatus muscle volume was measured. The infraspinatus muscle interference pattern and volume were compared with active GER. Results Interference pattern on EMG of the infraspinatus muscle was significantly related to the Mallet Score (P=0.0022), with a poor interference pattern associated with an approximately 7 times higher likelihood [odds ratio=7.391; 95% confidence interval (2.054, 26.588)] of poor active GER. Infraspinatus muscle volume decrease on MRI was also significantly related to active GER (P=0.0413), with each percent volume decrease corresponding to an increase of 0.094 in the odds of having a poor Mallet Score for active GER [odds ratio=1.094; 95% confidence interval (1.004, 1.193)]. Conclusions The interference pattern of the infraspinatus muscle on EMG and the infraspinatus muscle volume on MRI are strongly related to active GER as assessed by the Mallet Score. Integrating clinical assessment with electrophysiological and imaging findings may improve the accuracy in evaluating shoulder dysfunction in NBPP and provide improved guidance in selecting interventions specific to the patients pattern of deficits. Level of Evidence Diagnostic study, level II.