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BACKGROUND: The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure. METHODS: A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest. RESULTS: Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007). CONCLUSIONS: SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely. LEVEL OF EVIDENCE: Level IV--case series.
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Fraturas Múltiplas , Fraturas do Rádio , Fraturas Salter-Harris , Fraturas da Ulna , Criança , Humanos , Adolescente , Fraturas do Rádio/cirurgia , Incidência , Ulna/cirurgia , Rádio (Anatomia)/cirurgia , Lâmina de Crescimento , Fraturas da Ulna/terapia , Estudos RetrospectivosRESUMO
OBJECTIVES: The primary objective of the present study is to compare the radiographic outcomes and complications of two different techniques for lateral closing-wedge osteotomy in pediatric patients with cubitus varus. METHODS: We retrospectively identified patients treated at five tertiary care institutions: 17 underwent the Kirschner-wire (KW) technique, and 15 patients were treated with the mini external fixator (MEF) technique. Demographic data, previous treatment, pre- and postoperative carrying angle (CA), complications and additional procedures were recorded. Radiographic evaluation included assessment of the humerus-elbow-wrist angle (HEW), and the lateral prominence index (LPI). RESULTS: Patients treated with both KW and MEF achieved significant improvements in clinical alignment (mean pre-op CA -16 ± 6.1 degrees to mean post-op 8.9 ± 5.3 degrees, P < 0.001). There were no differences in final radiographic alignment or radiographic union time; however, time to achieve full elbow motion was faster in the MEF group (13.6 versus 34.3 weeks, P = 0.4547). Two patients (11.8%) in the KW group experienced complications, including one superficial infection and one failed correction that required unplanned revision surgery. Eleven patients in the MEF group underwent a planned second surgical procedure for hardware removal. CONCLUSIONS: Both fixation techniques are effective at correcting cubitus varus in the pediatric population. The MEF technique may have the advantage of shorter recovery of elbow range of motion but may require sedation for hardware removal. The KW technique may present a slightly higher complication rate.
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Articulação do Cotovelo , Fraturas do Úmero , Deformidades Articulares Adquiridas , Humanos , Criança , Fraturas do Úmero/complicações , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Deformidades Articulares Adquiridas/diagnóstico por imagem , Deformidades Articulares Adquiridas/cirurgia , Osteotomia/métodos , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/cirurgia , Amplitude de Movimento ArticularRESUMO
PURPOSE: Pediatric trigger finger (PTF) is an acquired condition that is uncommon and anatomically complex. Currently, the literature is characterized by a small number of retrospective case series with limited sample sizes. This investigation sought to evaluate the presentation, management, and treatment outcomes of PTF in a large, multicenter cohort. METHODS: A retrospective review of pediatric patients with a diagnosis of PTF between 2009 and 2020 was performed at three tertiary referral hospitals. Patient demographics, PTF characteristics, treatment strategies, and outcomes were abstracted from the electronic medical records. Patients and families also were contacted by telephone to assess the downstream persistence or recurrence of triggering symptoms. RESULTS: In total, 321 patients with 449 PTFs were included at a mean follow-up of 3.9 ± 4.0 years. There were approximately equal numbers of boys and girls, and the mean age of symptom onset was 5.4 ± 5.1 years. The middle (34.7%) and index (11.6%) fingers were the most and least commonly affected digits, respectively. Overall, PTFs managed operatively achieved significantly higher rates of complete resolution compared with PTFs managed nonsurgically (97.1% vs 30.0%). Seventy-five percent of PTFs that achieved complete resolution with nonsurgical management did so within 6 months, and approximately 90% did so within 12 months. Patients with multidigit involvement, higher Quinnell grade at presentation, or palpable nodularity were significantly more likely to undergo surgery. There was no significant difference in the rate of complete resolution between splinted versus not splinted PTFs or across operative techniques. CONCLUSIONS: Only 30% of the PTFs managed nonsurgically achieved complete resolution. Splinting did not improve resolution rates in children treated nonsurgically. In contrast, surgical intervention has a high likelihood of restoring motion and function of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Dedo em Gatilho , Masculino , Feminino , Humanos , Criança , Lactente , Pré-Escolar , Dedo em Gatilho/terapia , Dedo em Gatilho/cirurgia , Estudos Retrospectivos , Dedos , Resultado do Tratamento , ContençõesRESUMO
INTRODUCTION: More than 1 in 4 pediatric fractures involves the distal radius. Most prior epidemiologic studies are limited to retrospective, single center investigations, and often include adults. This study aims to describe the contemporary epidemiology of pediatric distal radius fractures using prospectively collected data from a multicenter Pediatric Distal Radius Fracture Registry. METHODS: Patients aged 4 to 18 years diagnosed with a distal radius fracture from June 2018 through December 2019 at 4 tertiary care pediatric centers were screened and enrolled in this prospective longitudinal cohort study. Patients were excluded if they presented with bilateral distal radius fractures, polytrauma, or re-fracture. Demographic information, mechanism of injury, fracture characteristics, associated injuries, and procedural information were recorded. All radiographs were reviewed and measured. Descriptive statistics and bivariate analyses were performed. RESULTS: A total of 1951 patients were included. The mean age was 9.9±3.3 years, and 61.3% of patients were male ( P <0.001). Most injuries occurred during a high-energy fall (33.5%) or sports participation (28.4%). The greatest proportion of fractures occurred during the spring months (38.5%). Torus fractures (44.0%) were more common than bicortical (31.3%) or physeal (21.0%) fractures. Of the physeal fractures, 84.3% were Salter-Harris type II. Associated ulnar fractures were observed in 51.2% of patients. The mean age at injury was higher for patients with physeal fractures (11.6±2.9 y) than patients with torus or bicortical fractures (9.4±3.1 and 9.6±3.1 y, respectively; P <0.001). Thirty-six percent of distal radius fractures underwent closed reduction and 3.3% underwent surgical fixation. Patients treated with closed reduction were more likely to be male (68.7% vs. 57.2%; P <0.001), obese (25.3% vs. 17.2%; P <0.001), and have bicortical fractures (62.2% vs. 14.5%; P <0.001). CONCLUSIONS: Distal radius fractures in children have a male preponderance and are most likely to occur in the spring months and during high-energy falls and sports. Physeal fractures tend to occur in older children while torus and bicortical fractures tend to occur in younger children. LEVEL OF EVIDENCE: Level I-prognostic.
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Fraturas do Rádio , Fraturas do Punho , Adulto , Humanos , Masculino , Criança , Adolescente , Feminino , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/complicações , Estudos Retrospectivos , Estudos Prospectivos , Estudos Longitudinais , Rádio (Anatomia)RESUMO
BACKGROUND: Despite recent policy efforts to increase price transparency, obtaining estimated prices for surgery remains difficult for most patients and families. PURPOSE: Assess availability and variability of cost and self-pay discounts for pediatric anterior cruciate ligament (ACL) reconstruction in the United States. METHODS: This was a prospective study using scripted telephone calls to obtain price estimates and self-pay discounts for pediatric ACL reconstruction. From July to August 2020, investigators called 102 hospitals, 51 "top-ranked" pediatric orthopaedic hospitals and 51 "non-top ranked" hospitals randomly selected, to impersonate the parent of an uninsured child with a torn ACL. Hospital, surgeon, and anesthesia price estimates, availability of a self-pay discount, and number of calls and days required to obtain price estimates were recorded for each hospital. Hospitals were compared on the basis of ranking, teaching status, and region. RESULTS: Only 31/102 (30.3%) hospitals provided a complete price estimate. Overall, 52.9% of top-ranked hospitals were unable to provide any price information versus 31.4% of non-top-ranked hospitals ( P =0.027). There was a 6.1-fold difference between the lowest and highest complete price estimates (mean estimate $29,590, SD $14,975). The mean complete price estimate for top-ranked hospitals was higher than for non-top-ranked hospitals ($34,901 vs. $25,207; P =0.07). The mean complete price estimate varied significantly across US region ( P =0.014), with the greatest mean complete price in the Northeast ($41,812). Altogether, 38.2% hospitals specified a self-pay discount, but only a fraction disclosed exact dollar or percentage discounts. The mean self-pay discount from top-ranked hospitals was larger than that of non-top-ranked hospitals ($18,305 vs. $9902; P =0.011). An average of 3.1 calls (range 1.0 to 12.0) over 5 days (range 1 to 23) were needed to obtain price estimates. CONCLUSION: Price estimates for pediatric sports medicine procedures can be challenging to obtain, even for the educated consumer. Top-ranked hospitals and hospitals in the Northeast region may charge more than their counterparts. In all areas, self-pay discounts can be substantial if they can be identified but they potentially create an information disadvantage for unaware patients needing to pay out-of-pocket. STUDY DESIGN: Economic; Level of Evidence II. WHAT IS KNOWN ABOUT THE SUBJECT: Previous studies have highlighted the importance of value-based health care decisions and deficits of price transparency in various fields including pediatric and orthopaedics procedures. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE: This study is the first to examine availability and variability of health care cost in pediatric sports medicine and the first to assess availability and magnitude of self-pay discounts, setting expectations for the uninsured patient incurring large out-of-pocket expenses.
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Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Criança , Custos de Cuidados de Saúde , Hospitais Pediátricos , Humanos , Estudos Prospectivos , Estados UnidosRESUMO
Cocaine use disorder (CUD) is characterized by a compulsive search for cocaine. Several studies have shown that cocaine users exhibit cognitive deficits, including lack of inhibition and decision-making as well as brain volume and diffusion-based white-matter alterations in a wide variety of brain regions. However, the non-specificity of standard volumetric and diffusion-tensor methods to detect structural micropathology may lead to wrong conclusions. To better understand microstructural pathology in CUD, we analyzed 60 CUD participants (3 female) and 43 non-CUD controls (HC; 2 female) retrospectively from our cross-sectional Mexican SUD neuroimaging dataset (SUDMEX-CONN), using multi-shell diffusion-weighted imaging and the neurite orientation dispersion and density imaging (NODDI) analysis, which aims to more accurately model microstructural pathology. We used Viso values of NODDI that employ a three-compartment model in white (WM) and gray-matter (GM). These values were also correlated with clinical measures, including psychiatric severity status, impulsive behavior and pattern of cocaine and tobacco use in the CUD group. We found higher whole-brain microstructural pathology in WM and GM in CUD patients than controls. ROI analysis revealed higher Viso-NODDI values in superior longitudinal fasciculus, cingulum, hippocampus cingulum, forceps minor and Uncinate fasciculus, as well as in frontal and parieto-temporal GM structures. We also found correlations between significant ROI and impulsivity, onset age of cocaine use and weekly dosage with Viso-NODDI. However, we did not find correlations with psychopathology measures. Overall, although their clinical relevance remains questionable, microstructural pathology seems to be present in CUD both in gray and white matter.
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Transtornos Relacionados ao Uso de Cocaína/patologia , Cocaína/farmacologia , Substância Cinzenta/patologia , Hipocampo/patologia , Neuritos/patologia , Substância Branca/patologia , Adulto , Encéfalo/patologia , Estudos Transversais , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Comportamento Impulsivo , Imageamento por Ressonância Magnética , Masculino , México , Estudos RetrospectivosRESUMO
PURPOSE: Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients. METHODS: This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up. RESULTS: A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients. CONCLUSIONS: Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
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Cistos Glanglionares , Humanos , Criança , Pré-Escolar , Adolescente , Cistos Glanglionares/cirurgia , Dor , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort. METHODS: A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores. RESULTS: A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores. CONCLUSIONS: Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.
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Cistos Glanglionares , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Cistos Glanglionares/epidemiologia , Mãos , Humanos , Masculino , Estudos Prospectivos , Punho , Articulação do Punho/diagnóstico por imagemRESUMO
BACKGROUND: Patient-reported outcome (PRO) instruments measure health status in a variety of domains. With the proliferation of mobile phones, delivering PROs across patient-friendly platforms (eg, apps, text messaging) may increase completion rates, particularly among children. The purpose of this study was to validate the collection of common knee PROs in sports medicine with text messaging by correlating text-messaging responses with paper delivery in adolescents. METHODS: Patients presenting to a hospital-based pediatric orthopaedic sports medicine clinic with a knee injury were enrolled prospectively. Paper versions of the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and the Pediatric Functional Activity Brief Scale (Pedi-Fab Scale) were completed during initial clinic visits. Over the next 72 hours, patients completed the text message delivery of the Pedi-IKDC and Pedi-Fab Scale. Correlations between paper and text message delivery of the 2 PROs were assessed. RESULTS: Ninety-one patients (mean age: 16.0±2.0 y; 48% females) enrolled in the text-messaging study, with 55 (60.4%) completing the Pedi-Fab Scale, 48 (52.7%) completing the Pedi-IKDC, and 39 (42.9%) completing both PROs. The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-Fab Scale was 0.95 (P<0.001; 95% confidence interval, 0.91-0.97). The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-IKDC was 0.96 (P<0.001; 95% confidence interval, 0.93-0.98). Average Pedi-Fab scores on paper (M=12.7) and mobile phone (M=12.3) were not significantly different (P=0.52). Similarly, average Pedi-IKDC scores on paper (M=68.8) and mobile phone (M=67.7) were not significantly different (P=0.41). Average completion time for the text delivered Pedi-Fab and Pedi-IKDC were 102±224 and 159±155 minutes, respectively. High school enrollment (P=0.025), female sex (P=0.036), and race (P=0.002) were significantly associated with text completion of Pedi-IKDC. CONCLUSIONS: Text message delivery using mobile phones permits valid assessment of Pedi-IKDC and Pedi-Fab scores in adolescents. Questionnaire delivery by automated text messaging allows asynchronous response and may increase compliance and reduce the labor cost of collecting PROs. LEVEL OF EVIDENCE: Level III-prospective cohort study.
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Traumatismos do Joelho/fisiopatologia , Articulação do Joelho/fisiopatologia , Medidas de Resultados Relatados pelo Paciente , Medicina Esportiva/métodos , Envio de Mensagens de Texto , Adolescente , Telefone Celular , Criança , Coleta de Dados/métodos , Escolaridade , Feminino , Humanos , Masculino , Estudos Prospectivos , Grupos Raciais , Fatores SexuaisAssuntos
Analgésicos Opioides/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Custos Hospitalares , Fraturas do Úmero/cirurgia , Cetorolaco/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Criança , Hospitalização/economia , Humanos , Tempo de Internação/economia , Manejo da DorRESUMO
Purpose: Distal radius fractures (DRFs) are common pediatric injuries typically treated with closed reduction and casting. A substantial number of these fractures fail nonsurgical management, occasionally requiring surgical intervention. Risk factors associated with an unsuccessful initial closed reduction (UIR) attempt or loss of reduction (LOR) after a successful closed reduction remain poorly characterized. Methods: This was a retrospective investigation of pediatric patients with displaced DRFs treated by closed reduction and casting at a single children's hospital from 2013 to 2017. Patient factors (age, sex, and body mass index) and radiographic measurements (fracture type, fracture displacement, associated ulna fracture, and cast index) were evaluated to determine risk factors for UIR and LOR. Results: We identified 159 children (118 boys, mean age, 11 ± 3 years) with DRFs who underwent closed reduction and casting. An initial acceptable reduction was achieved in 81% of patients, and LOR occurred in 21.7%. Higher initial fracture translation in the sagittal or coronal plane and higher initial angulation in the coronal plane were associated with higher fluoroscopy times. Higher initial translation in the sagittal plane was independently associated with UIR. After closed reduction, residual translation in the sagittal plane and cast index were independent predictors for LOR. Fractures that were completely displaced in the sagittal plane were 6.2 times less likely to undergo an acceptable initial reduction, and fractures with any residual postreduction translation in the sagittal plane were 4.7 times more likely to demonstrate LOR. Conclusions: The most important factors predicting failure of nonsurgical management of pediatric DRFs are translation in the sagittal plane and cast index greater than 0.80. To optimize patient outcomes, these variables should be recognized by the treating provider and emphasized during simulation training of orthopedic and plastic surgery residents. Type of study/level of evidence: Prognostic III.
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Background: Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction. Methods: Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed. Results: 365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%. Conclusions: In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.Level of Evidence: Prognostic Level I.
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Microcirurgia/métodos , Paralisia do Plexo Braquial Neonatal/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Análise de Variância , Traumatismos do Nascimento/diagnóstico , Traumatismos do Nascimento/cirurgia , Estudos de Coortes , Eletromiografia/métodos , Feminino , Seguimentos , Humanos , Lactente , Modelos Logísticos , Masculino , Análise Multivariada , Paralisia do Plexo Braquial Neonatal/diagnóstico , Exame Físico/métodos , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica/fisiologia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: There is a need for improved opioid stewardship in orthopedic surgery through multimodal analgesia strategies. Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning (CRPP) for displaced supracondylar humerus (SCH) fracture may decrease pain, reduce opioid requirements, and decrease hospitalization costs. METHODS: Retrospective case-control investigation of children (aged, 1 to 14) treated with CRPP for closed, modified Gartland type III extension-type SCH fractures at a single children's hospital between 2011 and 2017. Patients that received ketorolac perioperatively (cases) were randomly matched 1:2 by sex and age (±1 y) with patients that did not receive ketorolac (controls). Data abstraction included demographic and perioperative details including inpatient Wong-Baker FACES pain ratings and analgesic requirements. Analysis included 2-tailed Mann-Whitney U and χ tests. RESULTS: In total, 342 patients were studied including 114 cases and 228 controls. Age (mean, 6.2±2.4 y), sex ratio (M:F, 1.28:1), operative time, and number of pins used were equivalent between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7±1.9) than in controls (1.4±2.6, P=0.017), as well as at 30 to 120 minutes postoperatively (1.1±2.3 and 1.7±2.8, respectively, P=0.036), as seen in Figure 1. Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0±0.6) than control patients (1.2±0.5, P=0.003). Mean postoperative length-of-stay (LOS) was 50.0% longer for control patients (20.4±11.3 h) than the ketorolac patients (13.6±8.8 h, P<0.001). Ketorolac administration was associated with 40.4% lower inpatient hospitalization cost compared to control patients, providing a 33.8 times return on investment. There was no difference in the 90-day complication rate between patient groups (P=0.905). CONCLUSIONS: The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Perioperative ketorolac is also associated with reduced LOS following CRPP for supracondylar humerus fractures and offers significant cost savings opportunities. LEVEL OF EVIDENCE: Level 3-Therapeutic: Case-Control Study.
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Anti-Inflamatórios não Esteroides/administração & dosagem , Fraturas do Úmero/cirurgia , Cetorolaco/administração & dosagem , Adolescente , Analgésicos Opioides/administração & dosagem , Pinos Ortopédicos , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Fixação Intramedular de Fraturas , Custos Hospitalares , Humanos , Fraturas do Úmero/economia , Lactente , Tempo de Internação , Masculino , Manejo da Dor , Dor Pós-Operatória/prevenção & controle , Philadelphia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP. MATERIALS AND METHODS: The 1997 to 2012 Kids' Inpatient Database (KID) was analyzed for this study. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups. RESULTS: The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5-121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1). CONCLUSIONS: This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
Assuntos
Traumatismos do Nascimento/epidemiologia , Neuropatias do Plexo Braquial/epidemiologia , Clavícula/lesões , Fraturas Ósseas/epidemiologia , Distocia do Ombro/epidemiologia , Plexo Braquial/lesões , Conjuntos de Dados como Assunto , Feminino , Humanos , Recém-Nascido , Masculino , Gravidez , Prevalência , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To (1) define a single institution's rate of open reduction for operative pediatric supracondylar humerus (SCH) fractures; (2) describe variability by surgeon in rates of irreducible fracture (IRF) and open reduction; and (3) determine whether variation in opening rate correlated with surgeon experience. DESIGN: Retrospective analytic study. SETTING: Urban tertiary care Level 1 trauma center. PATIENTS/PARTICIPANTS: Twelve fellowship-trained pediatric orthopaedists. MAIN OUTCOME MEASUREMENTS: Rate of open reduction for operatively treated SCH fractures (OTA/AO 13-M/3). RESULTS: One thousand two hundred twenty-nine type II SCH fractures (none of which required open reduction) were excluded from the analysis. A total of 1365 other SCH fractures were included: 1302 type III fractures, 27 type IV fractures, and 36 fractures with unspecified type. 2.9% of type III and 22.2% of type IV fractures required open reduction. None of the injuries with unspecified type required open reduction. The rate of open reduction among 11 surgeons ranged from 0% to 15.0% in type III-IV fractures (P = 0.001). 86% (38/44) of open reductions were performed for IRF. In regression analysis, patient age was associated with open reduction for IRF (odds ratio 1.22, P = 0.001), but surgeon years-in-practice (0.321) and number of previous cases (0.327) were not associated with open reduction. Other indications for opening included suspected vascular or neurologic injury. CONCLUSIONS: Open reduction was rarely performed in this sample, but IRF was the dominant indication for opening. We found true variation in surgeons' rates of performing open reductions. More experience was not correlated with decreased likelihood of open reduction. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Redução Aberta/métodos , Traumatismos dos Nervos Periféricos/prevenção & controle , Adolescente , Fatores Etários , Atitude do Pessoal de Saúde , Criança , Pré-Escolar , Estudos de Coortes , Articulação do Cotovelo/fisiopatologia , Feminino , Consolidação da Fratura/fisiologia , Humanos , Escala de Gravidade do Ferimento , Masculino , Cirurgiões Ortopédicos/tendências , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Centros de Traumatologia , Resultado do TratamentoRESUMO
OBJECTIVES: To determine if high body mass index (BMI) increases the risk of loss of reduction (LOR) following closed reduction and casting for displaced concomitant fractures of the radial and ulnar shafts in pediatric patients. DESIGN: Retrospective cohort study. SETTING: A single, tertiary care, urban children's hospital. PATIENTS/PARTICIPANTS: Pediatric patients 2-18 years of age with closed, displaced, concomitant diaphyseal fractures of the radius and ulna (OTA/AO 22-A3) who underwent closed reduction and casting at the study site. MAIN OUTCOME MEASURES: BMI percentile of ≥95 was defined as obese. For nonobese patients, BMI percentile of ≥85 was defined as overweight. BMI percentile category, fracture angulation, sex, age, fracture location, and number of follow-up visits were recorded. Radiographs and health records were reviewed to note clinical and radiographic cases of LOR. The primary outcome was LOR (clinical or radiographic). RESULTS: Overall, 124 subjects (74 male and 50 female subjects) underwent acceptable closed reduction and casting. Median patient age was 7.6 years (range, 2.2-17.8 years). There were 14 cases of LOR. LOR rates were 7.2%, 16.7%, and 44.4% for the nonoverweight, overweight, and obese cohorts, respectively (P = 0.005). Regression analysis revealed that LOR was positively associated with higher BMI category (odds ratio for overweight 4.49; P = 0.082; odds ratio for obese 7.52; P = 0.020) and patient age in years (odds ratio, 1.38; P = 0.001). CONCLUSIONS: Given the high risk of LOR in overweight and obese children with displaced concomitant fractures of the radial and ulnar shafts, our findings suggest that attentive and frequent follow-up is warranted. In these patients, the initial reduction should be closely scrutinized, and a lower threshold for surgical fixation may be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Obesidade/complicações , Fraturas do Rádio/terapia , Fraturas da Ulna/terapia , Adolescente , Moldes Cirúrgicos , Criança , Pré-Escolar , Redução Fechada/efeitos adversos , Diáfises , Feminino , Humanos , Masculino , Fraturas do Rádio/complicações , Estudos Retrospectivos , Fatores de Risco , Falha de Tratamento , Fraturas da Ulna/complicaçõesRESUMO
PURPOSE: To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS: Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS: Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS: The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Assuntos
Dedos , Tenossinovite/diagnóstico , Tenossinovite/microbiologia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Resistência Microbiana a Medicamentos , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Tenossinovite/terapia , Adulto JovemRESUMO
OBJECTIVES: To investigate the relationship between obesity and distal radius fracture severity after low-energy trauma and to identify patient-specific risk factors predictive of increasing fracture severity. DESIGN: Retrospective review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Four hundred twenty-three adult subjects with a history of fracture of the distal radius resulting from a fall from standing height. INTERVENTION: Demographic data and injury characteristics were obtained. Preoperative wrist radiographs were reviewed and classified by the OTA classification system. Distal radius fractures were categorized as simple [closed and extra-articular (OTA 23-A)] and complex [intra-articular (OTA 23-B or 23-C) or open fracture or concomitant ipsilateral upper extremity fracture]. Multivariate logistic regression was completed to model the probability of incurring a complex fracture. MAIN OUTCOME MEASUREMENTS: Simple versus complex fracture pattern. RESULTS: Average age at the time of injury was 53.8 years (range, 18.9-98.4). Seventy-nine percent of subjects were female. The average body-mass index was 28.1 (range, 13.6-59.5). Two hundred forty-four patients (58%) suffered complex distal radius fractures per study criteria. Obese patients (body-mass index > 30) demonstrated increased fracture severity as per the OTA classification (P = 0.039) and were more likely to suffer a complex injury (P = 0.032). Multivariate regression identified male gender, obesity, and age ≥50 as independent risk factors for sustaining a complex fracture pattern. CONCLUSIONS: Obesity is associated with more complex fractures of the distal radius after low-energy trauma, particularly in elderly patients. This relationship may have important epidemiologic implications predictive of future societal fracture burden and severity in an obese, aging population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.