The right turn around: Penrose tourniquet application in paediatrics

INTRODUCTION

Commercially available tourniquets are ill-suited for paediatric patients with limb circumferences smaller than the required mechanism, forcing surgeons to improvise. This study aimed to quantify pressures exerted by the Penrose tourniquet when applied on a phantom model and evaluate the intra-/inter-rater reproducibility of the technique previously proposed.

METHODS

Eight calibrated pressure sensors were distributed evenly along the inner and outer circumference of a silicon-based model. A 30cm-by-3.2 cm ARGYLE Penrose drain, 4-by-4 gauze, marker and ruler were used. The optimal interval for arterial occlusion was determined to be 70% of limb circumference. The tourniquet was secured using two half-knots formed by gauze.

RESULTS

Two-turns of the tourniquet about the model generated mean pressures (SD) of 209.43 (SD:35.98 mmHg) (95%CI: 195.85-224.00 mmHg) (outer-sensor) and 246.32 (SD:61.92 mmHg) (95%CI: 221.02-273.49 mmHg) (inner-sensor). Three-turns generated mean pressures of 302.07 (SD:23.98 mmHg) (95%CI: 292.29-312.53 mmHg) (outer-sensor) and 314.44 (SD:56.70 mmHg) (95%CI: 291.25-338.25 mmHg) (inner-sensor).

CONCLUSION

The Penrose tourniquet has clinical utility, particularly for patients where commercially available tourniquets are not suitable. Current application techniques generate inconsistent pressures. Using the existing model, further refinement can be done to improve the consistency and safety of the application. We recommend using intervals of slightly more than 70% of limb circumference and only two turns of the Penrose tourniquet during application.

LEVEL OF EVIDENCE

V.

Using the radiocoronoid line for diagnosis of elbow dislocation

The radiocapitellar line (RCL) has been widely used to diagnose elbow dislocation. However, there are limitations to the RCL, with the cartilaginous portion of bone making interpretation of radiographs difficult. The study aims to show that the radiocoronoid line, which connects two points on the medial aspect of the radius, proximal to the radial tuberosity, is more suited to diagnose elbow dislocations in the anterior-posterior projection. This study also observes factors affecting accuracy of the radiocapitellar line. The radiographs of 50 normal and 17 laterally dislocated elbows were obtained. An unbiased independent reviewer drew the radiocoronoid and radiocapitellar line (RCL). Four other blinded independent reviewers drew the RCL and the radiocoronoid line for 20 radiographs and repeated the process a week later. The accuracy of the RCL was assessed using distance away from bisection point of capitellum, and ratio (distance from the point where line crosses capitellum to lateral aspect of capitellum over the total width of capitellum). The relationship of the radio-coronoid line and the lateral aspect of coronoid fossa was assessed, with dislocation being the line lateral to it and normal being medial to or on it. The radiocoronoid line had a higher accuracy (95.5%) compared to RCL (32.8%), higher specificity (94%) compared to RCL (10%) as well as higher positive predictive value (85%) compared to RCL (27.4%). There was no intra- or inter-observer variability for the radio-coronoid line. Skeletal age statistically predicted the ratio for the male population ( P < 0.05), however, the independent variables did not statistically predict the dependent variables for the female and total population. The radiocoronoid line serves as an additional method to assess radiocapitellar joint lateral dislocation. It is more accurate and reliable than the radiocapitellar line in the anterior-posterior projection. Sex and skeletal age also influence the accuracy of the radiocapitellar line with the radiocapitellar line nearing the bisection point as skeletal age in males increases.

Retrospective analysis: risk factors predicting failure of closed reduction in pediatric diaphyseal forearm fractures treated with elastic stable intramedullary nails (ESINs)

LEVEL OF EVIDENCE

Level IV.

Dose reduction for minimizing radiation in displaced paediatric supracondylar humerus fractures: single vs. automated pulse mode

Conventional C-arm image intensifiers (CCA) are an essential and indispensable aid in modern orthopaedic surgery. CCAs are defaulted to auto-pulse mode which emit multiple pulses (or bursts) of radiation to obtain optimum image quality. The number of pulses per shot can be configured manually. The purpose of this study is to investigate the efficacy of the single pulse mode of CCA in reducing and fixing paediatric supracondylar humeral fractures (SCHF). A retrospective chart review of 99 paediatric patients who underwent closed reduction and percutaneous pinning of displaced SCHF was performed. Fifty-one consecutive cases operated with auto-pulse mode (group A). Another 48 consecutive cases were operated with the single-pulse mode (group B). Baumann's angle, operative duration and average radiation dose rate were recorded for comparison between both groups. Twenty postpinning images were randomly selected (10 from each group) to study intra- and interobserver reliability. Twelve doctors were recruited and tasked to identify if each X-ray was taken with the auto-pulse or single-pulse mode. This was repeated after 2 weeks. The patients in the auto-pulse mode group had a significantly higher mean radiation dose of 40.4 ± 32.51 cGycm2/min compared to that of 14.8 ± 3.24 cGycm2/min for the single-pulse group (P ≤ 0.001). All patients in both groups had Baumann's angle within normal range of 64-81°. No significant difference was noted in average intraoperative timings between both groups (P = 0.869). In the majority of cases, the doctors were unable to visually differentiate between the modes of CCA used. The single-pulse mode is an excellent alternative to the auto-pulse mode in fixing SCHF. It gives significantly lower radiation without compromising the surgical outcome. Level of evidence: Level III retrospective comparative study.

Polymetatarsia of the Foot without Polydactyly: A Case Report

CASE

We report a rare case of polymetatarsia without polydactyly. Our patient presented with pain and difficulty with shoewear. Radiographs showed an accessory metatarsal arising from the lateral aspect of the fourth metatarsal proximal metaphysis, fusing distally with the medial aspect of the fifth metatarsal head to form a single metatarsophalangeal joint. He was treated with a chevron osteotomy of the conjoined complex and an Akins osteotomy of the fifth proximal phalanx. Our patient recovered functionally, and his pain improved postoperatively.

CONCLUSION

The chevron osteotomy is an option for treating polymetatarsia without polydactyly with the aim of reducing the forefoot width.

LEVEL OF EVIDENCE

Case study, level 5.

Suture osteosynthesis in the bony reconstruction of thumb duplication

Metacarpal osteotomies are done to correct deviation deformity in thumb duplication. We describe a suture-only technique of metacarpal osteosynthesis, without using K-wires. Thirteen Flatt Type IV thumbs and five Wassel Type VII thumbs were reconstructed with this technique. The median follow-up was 23 months. After osteotomy, the metacarpal bone fragments were sutured together with 5-0 polyglactin or 4-0 polydioxanone sutures. Metacarpal fragment displacement was not observed on postoperative radiographs obtained at 1 and 2 weeks. Bony union was achieved at 6 weeks without loss of alignment. The metacarpophalangeal joint alignment was anatomical (≤5° deviation) in eight cases. The mean pre- and postoperative metacarpophalangeal joint alignments were 27° and 9°, respectively. The 11 patients who were available for grading with the Japanese Society for Surgery of the Hand Score were assessed as good. Complete internalization of the bony fixation eliminates infections associated with exposed K-wires without compromising the overall outcome.Level of evidence: IV.

Biomechanical investigation of 'figure of 8' flexor tendon repair techniques

This biomechanical study compared the original Al-Qattan repair with other modifications postulated to reduce bulk and friction, thereby potentially improving outcome. A total of 32 cadaveric digits with intact flexor apparatus were used. In each digit, the flexor digitorum profundus and flexor digitorum superficialis tendons were cut cleanly in Zone 2. We tested Al-Qattan's technique along with three modifications using stronger suture material and varying the number of strands across the repair site. Of the four repair techniques, the modified Al-Qattan's technique using two 'figure of 8' 4-0 Fiberwire core sutures (Group 4) had the best balance of ultimate tensile strength (50.9 N), 2 mm gapping force (38 N) and friction. The modified technique provided a stronger repair for early active mobilization and has less friction than the originally described repair.

An assessment of 2 objective measurements of web space position

PURPOSE

To describe 2 simple objective clinical methods of measuring the web position between fingers and to determine their intra-observer and inter-observer reliabilities.

METHODS

Two observers examined the second, third, and fourth web spaces on both hands of 30 adult healthy volunteers. The web index measured the web height as a relative ratio to constant anatomical landmarks on both fingers subtending the web. The dorsal web index took reference from the distance between the metacarpophalangeal and proximal interphalangeal joints, whereas the palmar web index was measured in relation to the distance between the most proximal basal digital and proximal interphalangeal joint creases. The intraclass correlation coefficient was used to determine intra-observer and inter-observer reliability.

RESULTS

Intraclass correlation coefficient values for intra-observer and inter-observer reliability were greater than 0.80, indicating excellent agreement. There was no statistically significant difference between the dorsal or palmar measurement methods in terms of reliability.

CONCLUSIONS

The dorsal or palmar measurement method may be reliably used in healthy adults to establish a web index that describes the web position. The palmar method is considered easier to perform.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Bipedicled homodigital neurovascular island flap for resurfacing dorsal digital defects amputation

Critical defects distal to the proximal interphalangeal joint are usually treated by heterodigital or reverse-flow homodigital flaps. Drawbacks of the former are potential donor digit stiffness and scarring, while the latter might be complicated by flap congestion. A bipedicled neurovascular island transposition flap design that preserves both proximal and distal extent of digital nerve and artery was employed to treat critical dorsal skin defect in two patients with encouraging results. Technical details and cadaveric study concepts are presented.

Antipronation spiral tenodesis--a surgical technique for the treatment of perilunate instability

Perilunate dislocations involve avulsion or rupture of both intrinsic and extrinsic ligaments around the lunate. If inadequately treated, these ligaments may not heal properly, inducing a particular type of carpal instability characterized by the loss of the ability of the carpus to resist pronation torques. Six ligaments protect the carpus against excessive intracarpal pronation: long radiolunate, palmar and dorsal lunotriquetral, dorsal scapholunate, dorsal intercarpal, and palmar scaphocapitate ligaments. Collectively, these antipronation ligaments have a spiral configuration around the carpus. This article describes a technique to reconstruct this spiral arrangement of ligaments using a strip of flexor carpi radialis. To illustrate the technique, we describe 1 clinical case with a follow-up of 34 months. The so-called antipronation spiral tenodesis is only indicated if the instability is easily reducible, without cartilage damage.

Hand fractures in children: epidemiology and misdiagnosis in a tertiary referral hospital

PURPOSE

To determine the local epidemiology of pediatric hand fractures and the rate of misdiagnosis.

METHODS

A retrospective study was performed on children aged 17 years and younger who were referred for actual or suspected metacarpal and phalangeal fractures. Medical records were reviewed for age at the time of injury, sex, fracture pattern, venue where the injury was sustained, injury mechanism, and diagnoses made by the referring doctor and hand surgeon. Differing diagnoses were considered misdiagnoses. The misdiagnosis rate was calculated as the percentage of misdiagnoses over the number of referrals.

RESULTS

Of 204 cases reviewed, emergency physicians referred 146 cases (72%), and primary health care physicians referred the rest. There were 193 cases of actual fractures in 181 patients and 16 cases of misdiagnosis. The fracture incidence peaked at 14 and 15 years. The median ages of children sustaining fractures of the distal phalanges, proximal phalanges, and metacarpals were 9, 12, and 15 years, respectively. The proximal phalanx was most commonly fractured (95 cases, 49%), as was the fifth ray (78 cases, 40%). Most fractures occurred at school (79 cases, 44%). Sports-related injury was the leading cause of fractures (70 cases, 39%). The misdiagnosis rate was 8% (16 of 204). The leading cause of misdiagnosis was misinterpretation of epiphyses (6 of 16), followed by missing multiple fractures (3 of 16).

CONCLUSIONS

The higher fracture incidence in teenagers is likely related to sports participation. Sports accounted for proximal fractures in older children, whereas young children sustained distal fractures through crushing injuries. Although the misdiagnosis rate seemed low, it might reflect that emergency physicians, who referred most of the cases, were adept at diagnosing fractures. To improve diagnostic accuracy, doctors should familiarize themselves with the location of epiphyses and look carefully for multiple fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis IV.

The oblique wedge osteotomy of the metacarpal condyle for reconstructing Wassel type IV thumb duplication in older children and adults

In reconstructing the Wassel type IV thumb duplication in infants, a deviation deformity of the retained thumb may be corrected by a closing transverse wedge osteotomy of the metacarpal neck. In older children and adults, this technique may cause avascular necrosis of the retained metacarpal condyle. We have addressed this problem by using an oblique wedge osteotomy of the metacarpal condyle. Ten patients (mean age, 18.9 years) underwent this procedure between 1993 and 2007. Patients with deviation angles of 30° or less had a closing wedge osteotomy, while those with deviation angles exceeding 30° had a rotational bone graft osteotomy. Deviation angles were corrected from a mean of 32° (range, 16° to 55°) to 0° in eight thumbs and 10° in two thumbs. There were no cases of avascular necrosis. All patients achieved good results by Tada's criteria. This technique effectively restores bony alignment of the thumb and preserves vascularity of the retained condyle.