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Zarro M, Goel R, Bickhart N, May CC, Abzug JM. Extensor Carpi Ulnaris Tendinopathy in Athletes: A Review of the Conservative and Rehabilitative Options. Hand (N Y) 2024; 19:407-413. [PMID: 36250572 PMCID: PMC11067837 DOI: 10.1177/15589447221127331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Extensor carpi ulnaris (ECU) tendinopathy is characterized by pain along the dorsal and ulnar aspect of the wrist and distal forearm. It is common in athletes who play stick and racquet sports due to repetitive motion and axial-loading through the wrist and forearm. Conservative therapeutic options include rest, the use of anti-inflammatory medications, and various injections. Rehabilitation via occupational or physical therapy includes therapeutic exercise, splinting, activity modification, manual therapy, and modalities. METHODS A narrative review of the literature on ECU tendinopathy is presented, and a case study approach is used to highlight the clinical management of this condition in an elite athlete. RESULTS An approach of medical management and rehabilitation allowed this patient to successfully return to play. CONCLUSIONS A combination of conservative measures and rehabilitation can be used to treat ECU tendinopathy and permit patients to be symptom-free and return to their desired activities.
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Affiliation(s)
- Michael Zarro
- University of Maryland School of Medicine, Baltimore, USA
| | - Ritu Goel
- University of Maryland Faculty Physicians, Inc., Baltimore, USA
| | - Nicole Bickhart
- University of Maryland Faculty Physicians, Inc., Baltimore, USA
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Nedder VJ, Chen KJ, May CC, Abzug JM, Liu RW. Developmental Anatomy of the Radial Bow in Pediatric Patients using 3D Imaging. J Pediatr Orthop 2024:01241398-990000000-00495. [PMID: 38389332 DOI: 10.1097/bpo.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND While radial bow shape is well characterized in adults, its development in children is not well understood. Previous studies on the radial bow use radiographs, thus, rotational positioning of the forearm could alter bowing measurements. This study used 3D imaging to better assess the pediatric radial bow. METHODS Computed tomography scans from the New Mexico Decedent Image Database were obtained for ages 2 to 16 (females) and 18 (males) (n=152). 3D models were generated using Slicer and Rhino software. Length of the entire radial bow (bicipital tuberosity to sigmoid notch), maximum radial bow, location of the maximum radial bow (bicipital tuberosity to the point of maximum bowing), and distal, middle, and proximal third radial bows were measured. RESULTS The length of the entire bow increased with age, with a strong correlation with age (r=0.90, P<0.01). The maximum bow increased with age, with a strong correlation with age (r=0.78, P<0.01). The maximum bow normalized to the length of the entire bow increased mildly with age, mean 0.059 ± 0.012 (r=0.24, P=0.0024), but seems to plateau around age 8. The location of the maximum bow increased with age (r=0.85, P<0.01). The normalized location of the maximum bow remained constant between ages, with a mean of 0.41 ± 0.10 (r=0.12, P=0.14). The normalized distal third bow mildly increased with age (r=0.34, P<0.01), the normalized middle third bow mildly increased with age (r=0.25, P<0.01), and the normalized proximal third bow remained constant between ages (r=0.096, P=0.24). CONCLUSIONS Normalized values for maximum, distal third, and middle third radial bow increase with age, while normalized values for location and proximal third radial bow remain relatively constant, suggesting the proportional shape of the radius changes during development, although qualitatively plateaus after age 8. LEVEL OF EVIDENCE Retrospective comparative study, Level-III.
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Affiliation(s)
- Victoria J Nedder
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, OH
| | - Kallie J Chen
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, OH
| | - Catherine C May
- Department of Pediatric Orthopedics, University of Maryland Medical Center, Baltimore, MD
| | - Joshua M Abzug
- Department of Pediatric Orthopedics, University of Maryland Medical Center, Baltimore, MD
| | - Raymond W Liu
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, OH
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Jacobs H, May CC, Abzug JM. What is causing this young athlete's wrist pain? JAAPA 2024; 37:46-48. [PMID: 38270656 DOI: 10.1097/01.jaa.0000997716.80311.1e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Haley Jacobs
- At the University of Maryland in Baltimore, Md., Haley Jacobs practices in pediatric orthopedics at the University of Maryland Medical Center, Catherine C. May is a clinical research coordinator in the School of Medicine, and Joshua M. Abzug is a professor in the School of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Weir TB, Abzug JM, Gaston RG, Osterman MN, Osterman AL. Hand Fractures-Management and the Complications That Inevitably Occur: Metacarpal Fractures. Instr Course Lect 2024; 73:285-304. [PMID: 38090905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Metacarpal fractures are among the most common hand fractures. To properly manage these injuries, surgeons must understand the anatomy, biomechanics, clinical assessment, surgical and nonsurgical treatment options, and potential complications. Metacarpal head fractures often require surgical treatment to restore the joint surface by using a variety of techniques. Metacarpal neck fractures are usually stable injuries that do not require surgical intervention, but surgeons must know when surgical intervention is indicated. Fractures of the metacarpal shaft can be treated surgically and nonsurgically and may be associated with large bone defects or soft-tissue injuries that require careful consideration. Finally, fractures involving the carpometacarpal joints must be promptly managed to avoid long-term complications, potentially requiring salvage procedures.
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Weir TB, Abzug JM, Gaston RG, Osterman AL, Osterman MN. Proximal Interphalangeal Joint Fractures. Instr Course Lect 2024; 73:325-346. [PMID: 38090907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Multiple fracture patterns can occur around the proximal interphalangeal joint and require surgeons to have a thorough understanding of the anatomy, clinical and radiographic examination, common fracture patterns, surgical and nonsurgical treatment options, and potential complications. Proximal phalangeal condylar fractures are typically managed surgically, because even nondisplaced fractures have a propensity for displacement. Middle phalangeal base fractures most commonly present as a volar lip fracture with or without dorsal subluxation or dislocation. Treatment options include extension block splinting or pinning, transarticular pinning, open reduction and internal fixation, external fixation, volar plate arthroplasty, and hemihamate arthroplasty. Less common fractures include dorsal lip fractures with or without volar subluxation or dislocation (the central slip fracture), lateral plateau impaction or avulsion injuries, and pilon fractures. The main goals in the management of middle phalangeal base fractures are to restore articular congruency and initial early range of motion, which are more important than obtaining an anatomic reduction.
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Rosenberg RE, Pressel DM, Rappaport DI, Abzug JM. Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting. Pediatrics 2024; 153:e2023064775. [PMID: 38105688 DOI: 10.1542/peds.2023-064775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/19/2023] Open
Abstract
The care of children with primary surgical diagnoses in acute care units often involves a shared surgical and medical model ("comanagement"). There are no formal guidelines for how such programs should be structured or care provided. We used a modified Delphi process, including national experts in pediatrics and pediatric medical subspecialties, pediatric surgical specialties, and pediatric anesthesiology, to develop recommendations for best practices for comanagement programs in community and tertiary care settings.
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Affiliation(s)
- Rebecca E Rosenberg
- Deceased; formerly Department of Pediatrics, New York University Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York
| | - David M Pressel
- Department of Pediatrics, Capital Health, Pennington, New Jersey
| | - David I Rappaport
- Department of Pediatrics, Nemours Children's Hospital of Delaware, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joshua M Abzug
- Departments of Orthopedics and Pediatrics, University of Maryland Medical Center and Children's Hospital, Baltimore, Maryland
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May CC, Conroy JL, Gaston RG, Weir TB, Osterman MN, Osterman AL, Abzug JM. Pediatric Phalanx Fractures. Instr Course Lect 2024; 73:497-510. [PMID: 38090920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.
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May CC, Abzug JM. Transphyseal Fracture of the Distal Humerus. Instr Course Lect 2024; 73:427-434. [PMID: 38090914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Transphyseal fractures of the distal humerus often occur in children younger than 4 years as a result of birth trauma, nonaccidental trauma, or falls from a low height. It is important to identify and treat these injuries in a timely manner to ensure successful management. Most transphyseal fractures of the distal humerus are treated with closed reduction and percutaneous pinning with the aid of an elbow arthrogram. The most common complication following a fracture is cubitus varus caused by growth arrest, malunion, or osteonecrosis of the medial condyle. Normal carrying angles may be restored through corrective lateral closing wedge osteotomy.
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Hariharan AR, Nugraha HK, Ho CA, Bauer A, Mehlman CT, Sponseller PD, O’Hara NN, Abzug JM. Transphyseal Humeral Separations: An Often-Missed Fracture. Children (Basel) 2023; 10:1716. [PMID: 37892379 PMCID: PMC10605817 DOI: 10.3390/children10101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Transphyseal humeral separations (TPHS) are rare injuries often associated with non-accidental trauma, necessitating accurate diagnosis. This study aims to assess the accuracy of diagnosis of TPHS. METHODS A retrospective review was conducted at five academic pediatric institutions to identify all surgically treated TPHS in patients up to 4 years of age over a 25-year period. Demographics, misdiagnosis rates, and reported misdiagnoses were noted. Comparative analyses were performed to analyze the effects of patient age and injury mechanism on misdiagnosis rates. RESULTS Seventy-nine patients (average age: 17.4 months) were identified, with injury mechanisms including accidental trauma (n = 49), non-accidental trauma (n = 21), Cesarean-section (n = 6), and vaginal delivery (n = 3). Neither age nor injury mechanism were significantly associated with diagnostic accuracy in the emergency department (ED)/consulting physician group. ED/consulting physicians achieved an accurate diagnosis 46.7% of the time, while radiologists achieved an accurate diagnosis 26.7% of the time. Diagnostic accuracy did not correlate with Child Protective Services (CPS) involvement or with a delay in surgery of more than 24 h. However, a significant correlation (p = 0.03) was observed between injury mechanism and misdiagnosis rates. CONCLUSION This multicenter analysis is the largest study assessing TPHS misdiagnosis rates, highlighting the need for raising awareness and considering advanced imaging or orthopedic consultation for accurate diagnosis. This also reminds orthopedic surgeons to always have vigilant assessment in treating pediatric elbow injuries. LEVEL OF EVIDENCE Level III-Retrospective Cohort Study.
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Affiliation(s)
- Arun R. Hariharan
- Paley Orthopedic and Spine Institute, West Palm Beach, FL 33407, USA
| | - Hans K. Nugraha
- Paley Orthopedic and Spine Institute, West Palm Beach, FL 33407, USA
| | - Christine A. Ho
- Children’s Health Dallas, Texas Scottish Rite Hospital for Children, Dallas, TX 75219, USA
| | - Andrea Bauer
- Boston Children’s Hospital, Boston, MA 02115, USA
| | - Charles T. Mehlman
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
| | | | - Nathan N. O’Hara
- Department of Orthopedics, University of Maryland Medical Center, Baltimore, MD 21201, USA (J.M.A.)
| | - Joshua M. Abzug
- Department of Orthopedics, University of Maryland Medical Center, Baltimore, MD 21201, USA (J.M.A.)
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Hamaker M, Codd CM, May CC, O'Hara NN, Abzug JM. Canal Fill of the Forearm Bones When Placing Intramedullary Nails in the Pediatric and Adolescent Populations. Hand (N Y) 2023:15589447231175514. [PMID: 37303157 DOI: 10.1177/15589447231175514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity. METHODS A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models. RESULTS Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) (P < .05). CONCLUSION This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily.
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Affiliation(s)
- Max Hamaker
- University of Maryland School of Medicine, Baltimore, USA
| | - Casey M Codd
- University of Maryland School of Medicine, Baltimore, USA
| | | | | | - Joshua M Abzug
- University of Maryland School of Medicine, Baltimore, USA
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Miller C, Dua K, O’Hara NN, May CC, Abzug JM. The Mental Health Implications of Obstetric Brachial Plexus Injuries (OBPI) on Parents. J Mother Child 2023; 27:217-221. [PMID: 37991975 PMCID: PMC10664834 DOI: 10.34763/jmotherandchild.20232701.d-23-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/03/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. The purpose of this study was to assess the mental health of mothers with newborns with an OBPI and identify resources that can help screen and treat mental health needs. MATERIAL AND METHODS Three groups of mothers were prospectively given a self-reported survey: 1) Newborns with OBPI; 2) Newborns in the nursery without OBPI; 3) Newborns in the neonatal intensive care unit (NICU). The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents' exposure to community violence, family support and use of drugs or alcohol. RESULTS Fifty-seven mothers were prospectively enrolled, and 30% (17/57) of mothers screened in for post-traumatic stress disorder (PTSD). OBPI mothers had significantly higher rates of PTSD symptoms when compared to mothers of children in the full-term nursery (difference = 36.4%; p < 0.01). No statistically significant difference was found between groups regarding depression symptoms. CONCLUSIONS OBPI can be very difficult to cope with for parents and family members. Forty-two percent of mothers with newborns with OBPI or children in the NICU screened in for PTSD symptoms. OBPI clinics should be staffed similarly to the NICU with clinical social workers to appropriately screen and treat parents with PTSD and depression symptoms.
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Affiliation(s)
- Catherine Miller
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Karan Dua
- Department of Orthopaedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine C. May
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua M. Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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Shaver TB, Hogarth DA, Case AL, May CC, Abzug JM. Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases. Hand (N Y) 2023:15589447231153166. [PMID: 36779506 DOI: 10.1177/15589447231153166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Widening of the scapholunate (SL) interval greater than 2 mm is diagnostic of an injury in adults; however, this absolute number cannot be used for skeletally immature individuals due to the ossification of the carpal bones. The purpose of this study was to determine age-appropriate normative values for the radiographic SL interval in the skeletally immature population. METHODS Normal pediatric wrist radiographs were identified. The radiographic SL interval was measured as the distance between the scaphoid and the lunate at the mid-joint space between the scaphoid and the lunate, and the SL and capitolunate angles were measured on lateral views. An initial inter-rater reliability assessment was completed with strong inter-rater reliability. RESULTS In all, 529 radiographic series of children (276 male), aged 4 to 17 years, were reviewed. A negative linear correlation between chronological age and distance at the mid-joint space was observed. The average values for the radiographic SL interval ranged from 9.07 to 1.57 mm. The average SL and capitolunate angles were 52.0° and 10.6°, respectively. No linear relationship was found between chronological age and SL or capitolunate angle (R = 0.07 and 0.03, respectively). CONCLUSIONS The visible radiographic distance between the scaphoid and the lunate decreases with increasing age as the carpal bones ossify. The normative values defined in this study can be used to determine whether a true widening of the SL interval is present in the pediatric population. No linear relationship exists between chronological age and SL or capitolunate angle.
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Affiliation(s)
| | | | | | | | - Joshua M Abzug
- University of Maryland School of Medicine, Baltimore, USA
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Case AL, Ty JM, Chu A, Ho CA, Bauer AS, Abzug JM. Variation Among Surgeons Regarding the Use of Preoperative Antibiotics in Percutaneous Pinning Procedures of the Upper Extremity in the Pediatric Population. Hand (N Y) 2022; 17:558-565. [PMID: 32757780 PMCID: PMC9112736 DOI: 10.1177/1558944720944259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Preoperative antibiotics may not be necessary, given the very low infection rates associated with percutaneous pinning (PP) procedures of the upper extremity (UE). The purpose of this study was to determine the patterns and variation surrounding the use of preoperative antibiotics when performing PP procedures of the child's UE. Methods: A survey was sent to all members of Pediatric Orthopedic Society of North America to assess the use and opinions regarding preoperative antibiotics for PP procedures of the UE. Queries included the surgeon's current practice and thoughts regarding the need for preoperative antibiotics based on the anatomical location of the procedure. Results: Eight-one percent of the 295 respondents routinely order preoperative antibiotics for all PP procedures of the UE; however, only 60% felt that all patients must receive preoperative antibiotics. The requirement for preoperative antibiotics varied based on the anatomical location-81% for shoulder, 70% for elbow, 66% for wrist, and 62% for hand/finger. Canadian surgeons were significantly less likely to believe that preoperative antibiotics must be used in all UE cases, all shoulder cases, and all elbow cases (all Ps = .04). Conclusion: The vast majority (81%) of surgeons surveyed routinely prescribe antibiotics for PP procedures of the UE despite the fact that 40% of surgeons felt that antibiotics were not necessary for all procedures. As the PP procedure is performed more distally on the UE, fewer surgeons feel preoperative antibiotics are necessary. Future studies assessing infection rates with and without the use of preoperative antibiotics are necessary to determine the true need for these medications.
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Affiliation(s)
| | - Jennifer M. Ty
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Alice Chu
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | | | - Joshua M. Abzug
- University of Maryland School of Medicine, Baltimore, MD, USA
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Shanks C, Schaeffer T, Falk DP, Nunziato C, Hogarth DA, Bauer AS, Shah AS, Gottschalk H, Abzug JM, Ho CA. The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts. J Hand Surg Am 2022; 47:341-347. [PMID: 35168830 DOI: 10.1016/j.jhsa.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 10/25/2021] [Accepted: 12/08/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. METHODS We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. RESULTS For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. CONCLUSIONS This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Carolyn Shanks
- University of Texas at Southwestern School of Medicine, Dallas, TX
| | | | - David P Falk
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Carl Nunziato
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Danielle A Hogarth
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Andrea S Bauer
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
| | - Apurva S Shah
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Joshua M Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Christine A Ho
- Scottish Rite for Children, Dallas, TX; Department of Orthopaedics, Children's Medical Center Dallas, Dallas, TX; Department of Orthopaedics, University of Texas Southwestern School of Medicine, Dallas, TX.
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Goel R, Santurri L, Fruth S, Abzug JM, Geigle PR. Telerehabilitation Use With Spinal Cord Injury: Occupational Therapists' Perspective. Am J Occup Ther 2022; 76:23201. [PMID: 35157754 DOI: 10.5014/ajot.2022.045831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Telerehabilitation provides people with spinal cord injury (SCI) an alternative mode of accessing specialized health care. Further research on occupational therapy practitioners' perspectives of telerehabilitation may provide additional evidence for clinical practice implementation. OBJECTIVE To explore urban occupational therapists' perspectives on the benefits of and barriers to telerehabilitation use with SCI. DESIGN A qualitative study design using a demographic questionnaire and a single, individual semistructured interview. Thematic analyses included member checking, constant comparative analysis, triangulation, and self-description and self-reflexivity. SETTING Residential and community settings. PARTICIPANTS Six occupational therapists with a range of experience in SCI rehabilitation were recruited using purposeful sampling. RESULTS Six participants were interviewed, and four primary themes emerged: (1) communication, (2) personal factors, (3) benefits, and (4) barriers. CONCLUSIONS AND RELEVANCE Telerehabilitation offers numerous potential benefits for SCI intervention. This study provides an understanding of practitioner concerns and potential barriers to use. The results indicate that a hybrid model incorporating both in-person and distance-based treatment is likely optimal. What This Article Adds: Our results provide information that addresses practitioner concerns and recommendations for the use of telerehabilitation with people with SCI. As practitioner concerns are identified and addressed, telerehabilitation may increase in the U.S. health care system, potentially facilitating an alternative treatment delivery method for underserved populations.
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Affiliation(s)
- Ritu Goel
- Ritu Goel, DHSc, MS, OTR/L, is Occupational Therapist, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore;
| | - Laura Santurri
- Laura Santurri, PhD, MPH, CPH, is Director, Doctor of Health Science Program, and Chair, Department of Interprofessional Health & Aging Studies, College of Health Sciences, University of Indianapolis, Indianapolis, IN
| | - Stacie Fruth
- Stacie Fruth, PT, DHSc, OCS, is Director, Doctor of Physical Therapy Program, and Founding Chair, Department of Physical Therapy, Western Michigan University, Kalamazoo
| | - Joshua M Abzug
- Joshua M. Abzug, MD, is Director of Pediatric Orthopedics, University of Maryland Medical Center, and Associate Professor, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore
| | - Paula Richley Geigle
- Paula Richley Geigle, PT, MS, PhD, is Research Specialist, Charles George Department of Veterans Affairs Medical Center, Asheville, NC
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16
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Abzug JM, Miller E, Case AL, Hogarth DA, Zlotolow DA, Kozin SH. Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy. Hand (N Y) 2022; 17:55-59. [PMID: 32188298 PMCID: PMC8721786 DOI: 10.1177/1558944720911211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.
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Affiliation(s)
- Joshua M. Abzug
- University of Maryland School of Medicine, Baltimore, USA,Joshua M. Abzug, Department of Orthopaedics, University of Maryland School of Medicine, One Texas Station Court, Suite 300, Timonium, Baltimore, MD 21093, USA.
| | - Elie Miller
- University of Maryland School of Medicine, Baltimore, USA
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17
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Wilson K, Usami Y, Hogarth D, Scheiber AL, Tian H, Oichi T, Wei Y, Qin L, Otsuru S, Toyosawa S, Iwamoto M, Abzug JM, Enomoto-Iwamoto M. Analysis of Association between Morphometric Parameters of Growth Plate and Bone Growth of Tibia in Mice and Humans. Cartilage 2021; 13:315S-325S. [PMID: 31997656 PMCID: PMC8804827 DOI: 10.1177/1947603519900800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The purposes of this study are to evaluate which growth plate parameters are associated with bone growth in mice and to compare the mouse results with those in humans. DESIGN The sagittal sections of the proximal growth plate of the mouse tibia from neonate to young adult stages were subjected to histomorphometric and functional analyses. The radiographic images of tibias of human patients until puberty were analyzed to obtain the tibia length and the proximal growth plate height. It was found that a linear correlation best modeled the relationship between the growth plate variables with the tibia growth rate and length. RESULTS In mice, total height, resting zone height, combined height of the proliferation and prehypertrophic zones, proliferation activity, and the total width of tibia growth plate showed high linear correlation with tibia bone length and bone growth rate, but the hypertrophic zone height and the growth plate area did not. In both mice and humans, the total growth plate width of tibia was found to have the strongest correlation with tibia length and growth rate. CONCLUSIONS The results validated that growth plate total height, the height of the resting zone and cell proliferation activity are appropriate parameters to evaluate the balance between growth plate activity and bone growth in mice, consistent with previous reports. The study also provided a new growth plate parameter candidate, growth plate width for growth plate activity evaluation in both mouse and human tibia bone.
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Affiliation(s)
- Kimberly Wilson
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Yu Usami
- Department of Oral Pathology, Osaka
University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Danielle Hogarth
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Amanda L. Scheiber
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Hongying Tian
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Takeshi Oichi
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Yulong Wei
- Mckay Orthopaedic Research Laboratory,
Department of Orthopaedic Surgery, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, PA, USA
| | - Ling Qin
- Mckay Orthopaedic Research Laboratory,
Department of Orthopaedic Surgery, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, PA, USA
| | - Satoru Otsuru
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Satoru Toyosawa
- Department of Oral Pathology, Osaka
University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Masahiro Iwamoto
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Joshua M. Abzug
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA
| | - Motomi Enomoto-Iwamoto
- Department of Orthopaedics, School of
Medicine, University of Maryland, Baltimore, MD, USA,Motomi Enomoto-Iwamoto, Department of
Orthopaedics, School of Medicine, University of Maryland, Baltimore, 20 Penn
Street, HSFII S022, Baltimore, MD, 21209, USA.
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18
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Pu A, Jauregui JJ, Salmons HI, Weir TB, Abzug JM, Gilotra MN. Radiographic evaluation of osteochondritis dissecans of the humeral capitellum: A systematic review. J Orthop 2021; 27:114-121. [PMID: 34594097 DOI: 10.1016/j.jor.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/12/2021] [Indexed: 02/01/2023] Open
Abstract
Background The purpose of this study was to evaluate radiographic-based classification systems for osteochondritis dissecans (OCD) of the capitellum and determine their agreement with intraoperative findings. Methods Using PRISMA guidelines, we analyzed 44 studies utilizing a total of 19 classification systems. Results Magnetic resonance imaging (MRI)-based systems showed better predictive value of intraoperative staging, and the Itsubo and Kohyama classifications showed best predictive value for lesion stability. Conclusions No classification system effectively correlated with intraoperative findings. A combination of radiograph, MRI, and computed tomography will most accurately determine OCD lesion stability. Level of evidence IV, Systematic Review.
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Affiliation(s)
- Alex Pu
- Department of Orthopedics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor Suite 300. Baltimore, MD, 21201, USA
| | - Julio J Jauregui
- Department of Orthopedics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor Suite 300. Baltimore, MD, 21201, USA
| | - Harold I Salmons
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tristan B Weir
- Department of Orthopedics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor Suite 300. Baltimore, MD, 21201, USA
| | - Joshua M Abzug
- Department of Orthopedics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor Suite 300. Baltimore, MD, 21201, USA
| | - Mohit N Gilotra
- Department of Orthopedics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor Suite 300. Baltimore, MD, 21201, USA
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19
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Weir TB, Zhang T, Jauregui JJ, Aneizi A, Schneider MB, Sajak PMJ, Gilotra MN, Abzug JM, Akabudike NM, Henn RF. Press Ganey Surveys in Patients Undergoing Upper-Extremity Surgical Procedures: Response Rate and Evidence of Nonresponse Bias. J Bone Joint Surg Am 2021; 103:1598-1603. [PMID: 33988529 DOI: 10.2106/jbjs.20.01467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patient satisfaction surveys are important measures of the patient experience that provide data for quality improvement. The purpose of this study was to establish the response rate and the factors associated with the completion of the Press Ganey (PG) Ambulatory Surgery Survey (PGAS) in patients who underwent ambulatory upper-extremity surgical procedures. METHODS A prospective orthopaedic registry at a single academic ambulatory surgical center was retrospectively reviewed for patients who underwent an upper-extremity surgical procedure from 2015 to 2019. The institutional PG database was queried to determine the patients who completed the PGAS postoperatively. The response rate was calculated, and baseline characteristics and patient-reported outcome measures were compared between responders and nonresponders. RESULTS Of the 1,489 patients included, 201 (13.5%) were responders and 1,288 (86.5%) were nonresponders. Differences existed in baseline characteristics between groups, with responders being significantly older (p = 0.004) and having significantly higher proportions of White race (p < 0.001), college education (p = 0.011), employment (p = 0.005), marriage (p = 0.006), and higher income earners (p < 0.001). Responders had significantly better baseline Patient-Reported Outcomes Measurement Information System scores across multiple domains (p < 0.05), but these differences were not clinically meaningful. CONCLUSIONS PGAS response rates were low (13.5%), and differences between responders and nonresponders may be utilized by hospitals to target feedback from underrepresented patient populations. Surgeons, policymakers, and health-care administrators should use caution with the interpretation of PGAS results because responders may not be representative of all patients.
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Affiliation(s)
- Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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20
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Abstract
PURPOSE OF REVIEW Although somewhat rare, upper extremity compressive neuropathies can occur in the pediatric and adolescent populations due to various etiologies. Some of the most common conditions seen include thoracic outlet syndrome, supracondylar process syndrome, cubital tunnel syndrome with subluxation of the ulnar nerve, and carpal tunnel syndrome. This review will focus on these diagnoses and how to address them in the pediatric and adolescent populations. RECENT FINDINGS Due to the rarity of upper extremity compressive neuropathies in the pediatric and adolescent populations, substantial advancement in the literature does not routinely occur. However, recent literature has found a difference in the rate of various subtypes of thoracic outlet syndrome in children versus adults. Additionally, cubital tunnel syndrome associated with ulnar nerve subluxation/instability has recently been found to have better outcomes following surgical decompression of the ulnar nerve and transposition than those with stable ulnar nerves. In summary, this review provides the most recent knowledge surrounding upper extremity compressive and entrapment neuropathies in the pediatric and adolescent populations.
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Affiliation(s)
- Casey M. Codd
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
| | - Joshua M. Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
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21
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Abzug JM, Bednar JM, Ezaki M, Hammert W, Jain SA, Kozin SH, Ladd AL, Nagle DJ. ASSH 75 Years: An Update of Progress Over the Past 25 Years. J Hand Surg Am 2020; 45:1070-1081. [PMID: 33153531 DOI: 10.1016/j.jhsa.2020.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 02/02/2023]
Abstract
This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.
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Affiliation(s)
- Joshua M Abzug
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD; Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD.
| | | | | | - Warren Hammert
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
| | - Sonu A Jain
- Division of Hand Surgery, Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Scott H Kozin
- Department of Hand and Upper Extremity, Shriner's Hospitals for Children, Philadelphia, PA
| | - Amy L Ladd
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Daniel J Nagle
- Department of Clinical Orthopaedic Surgery, Northwestern University, Chicago, IL
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22
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Abstract
Background: Upper extremity length and circumference abnormalities are present in a number of conditions in the pediatric population. In most cases, upper limb hypoplasia and hypertrophy are diagnosed when one limb appears substantially different from the other during physical examination. However, occasionally when this discrepancy exists, it can be difficult to determine which limb is the abnormal one. The purpose of this study was to establish normal values for upper extremity length, circumference, and rate of growth in children aged 0 to 17 years. Methods: In all, 377 participants had 4 measurements taken of each upper extremity: upper arm length, upper arm circumference, forearm length, and forearm circumference. Statistical analysis was performed to identify differences and rates of growth. Results: Mean values for arm and forearm length and circumference for each age, 0 to 17 years, were established. The determination of a child's expected arm length is dependent on his or her height, age, and sex, while the calculation of a child's expected forearm length depends on his or her weight, age, and sex. Male and female arms and forearms have similar growth rates of lengths and circumferences. No significant differences were found between right and left extremities for each of the 4 measurements taken. Conclusions: Contralateral limbs can be used for comparison of length and circumference of the arm and forearm in cases of unilateral upper extremity abnormality. The establishment of normal values for upper extremity length, circumference, and growth rate will be a useful diagnostic tool for upper extremity hypoplasia and hypertrophy.
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Affiliation(s)
| | | | | | | | - Joshua M. Abzug
- University of Maryland, Baltimore, USA,University of Maryland, Timonium, USA,Joshua M. Abzug, School of Medicine, University of Maryland, One Texas Station Court, Suite 300, Timonium, MD 21093, USA.
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23
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Shield W, Cellini A, Tian H, Wilson K, Dan Y, Abzug JM, Garcia S, Moritani N, Alferiev I, Chorny M, Takigawa M, Ng VY, Iwamoto M, Enomoto-Iwamoto M. Selective Agonists of Nuclear Retinoic Acid Receptor Gamma Inhibit Growth of HCS-2/8 Chondrosarcoma Cells. J Orthop Res 2020; 38:1045-1051. [PMID: 31808569 PMCID: PMC7162703 DOI: 10.1002/jor.24555] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/30/2019] [Indexed: 02/04/2023]
Abstract
Chondrosarcoma is the second most common primary bone sarcoma. Treatment of chondrosarcoma is limited to surgery due to radiation and chemotherapy resistance of this cancer. An ideal treatment for chondrosarcoma would be a well-tolerated, minimally invasive local or systemic treatment modality to halt or slow tumor growth prior to resection of local, unresectable local, or metastatic disease. Palovarotene, an agonist of nuclear retinoic acid receptor γ (RARγ) has shown therapeutic action for treatment of heterotopic ossification and osteochondroma without serious adverse effects in animal models. We hypothesized that selective agonists of RARγ would have an inhibitory effect on chondrosarcoma. All human chondrosarcoma specimens expressed RARγ as determined by immunohistochemical staining. The ΗCS-2/8 chondrosarcoma cell line, established from low-grade human chondrosarcoma, was used to examine the actions of RARγ agonists. In ΗCS2/8 pellet cultures, RARγ agonist treatment reduced the mass size and significantly decreased total glycosaminoglycan, protein amounts, and gene expression levels of cartilage matrix molecules when compared with control groups. Systemic treatment with RARγ agonists significantly inhibited the growth of ΗCS-2/8 cell transplants in vivo. Furthermore, local injection of RARγ agonist-loaded poly-lactic acid nanoparticles induced regression of the mass size of the transplants. Histologic analysis demonstrated that RARγ agonist treatment inhibited cell proliferation activity and stimulated encapsulation of the tumor. These findings indicate that RARγ agonists, including palovarotene, may have an anti-tumor effect on low-grade chondrosarcomas. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1045-1051, 2020.
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Affiliation(s)
- William Shield
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Ashley Cellini
- Department of Pathology, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Hongying Tian
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Kim Wilson
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Yang Dan
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Joshua M Abzug
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Sonia Garcia
- Department of Graduate Program of Molecular Medicine, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Norifumi Moritani
- Department of Oral and Maxillofacial Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ivan Alferiev
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Chorny
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Masaharu Takigawa
- Advanced Research Center for Oral and Craniofacial Sciences, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Vincent Y Ng
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Masahiro Iwamoto
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Motomi Enomoto-Iwamoto
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, Baltimore, Maryland, USA
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24
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Garcia SA, Tian H, Imamura-Kawasawa Y, Fisher A, Cellini A, Codd C, Herzenberg JE, Abzug JM, Ng V, Iwamoto M, Enomoto-Iwamoto M. Understanding the Action of RARγ Agonists on Human Osteochondroma Explants. Int J Mol Sci 2020; 21:E2686. [PMID: 32294904 PMCID: PMC7215996 DOI: 10.3390/ijms21082686] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 12/18/2022] Open
Abstract
Osteochondromas are cartilage-capped growths located proximate to the physis that can cause skeletal deformities, pain, limited motion, and neurovascular impingement. Previous studies have demonstrated retinoic acid receptor gamma (RARγ) agonists to inhibit ectopic endochondral ossification, therefore we hypothesize that RARγ agonists can target on established osteochondromas. The purpose of this study was to examine the action of RARγ agonist in human osteochondromas. Osteochondroma specimens were obtained during surgery, subjected to explant culture and were treated with RARγ agonists or vehicles. Gene expression analysis confirmed the up-regulation of RARγ target genes in the explants treated with NRX 204647 and Palovarotene and revealed strong inhibition of cartilage matrix and increased extracellular matrix proteases gene expression. In addition, immunohistochemical staining for the neoepitope of protease-cleaved aggrecan indicated that RARγ agonist treatment stimulated cartilage matrix degradation. Interestingly, cell survival studies demonstrated that RARγ agonist treatment stimulated cell death. Moreover, RNA sequencing analysis indicates changes in multiple molecular pathways due to RARγ agonists treatment, showing similarly to human growth plate chondrocytes. Together, these findings suggest that RARγ agonist may exert anti-tumor function on osteochondromas by inhibiting matrix synthesis, promoting cartilage matrix degradation and stimulating cell death.
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Affiliation(s)
- Sonia A. Garcia
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Hongying Tian
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Yuka Imamura-Kawasawa
- Departments of Pharmacology and Biochemistry and Molecular Biology, Institute for Personalized Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA;
| | - Aidan Fisher
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Ashley Cellini
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Casey Codd
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - John E. Herzenberg
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
- Pediatric Orthopaedics, Sinai Hospital, Baltimore, MD 21215, USA
| | - Joshua M. Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Vincent Ng
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Masahiro Iwamoto
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
| | - Motomi Enomoto-Iwamoto
- Department of Orthopaedics, University of Maryland School of Medicine, 20 Penn Street, HSFII, Baltimore, MD 21201, USA; (S.A.G.); (H.T.); (A.F.); (A.C.); (C.C.); (J.E.H.); (J.M.A.); (V.N.); (M.I.)
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25
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Dua K, Blevins CJ, O’Hara NN, Abzug JM. The Safety and Benefits of the Semisterile Technique for Closed Reduction and Percutaneous Pinning of Pediatric Upper Extremity Fractures. Hand (N Y) 2019; 14:808-813. [PMID: 29998759 PMCID: PMC6900694 DOI: 10.1177/1558944718787310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping. The semisterile technique utilizes minimal prep and draping, which was proven to be a viable alternative when treating pediatric supracondylar humerus fractures. The purpose of this study was to investigate the safety and benefits of the semisterile technique for CRPP of pediatric upper extremity fractures. Methods: A retrospective cohort study was conducted of pediatric patients who underwent CRPP of an upper extremity fracture over a 4-year period. Demographic data, fracture type/location, and the type of prep technique (full-prep vs semisterile) were recorded. Qualities of intraoperative care were assessed, and postoperative care parameters were compared. Patient outcomes for the 2 techniques were compared using bivariate analyses. Results: In total, 219 patient records were reviewed including 160 in the semisterile group and 59 in the full-prep group. When comparing intraoperative parameters between the full-prep and semisterile techniques, the average room setup time was similar (20.6 vs 18.8 minutes, P = .52). However, the procedure times (32.1 vs 26.9 minutes, P = .04) were significantly shorter in the semisterile group. Nearly a 10-minute decrease in total time in the operating room was present while utilizing the semisterile technique (62.8 vs 53.6 minutes, P < .01). There were no statistical differences in complication rates between prep groups (P = .31), and there were no infections while utilizing the semisterile technique. Conclusions: The semisterile technique is a safe and efficient alternative that may be used when performing CRPP of pediatric upper extremity fractures.
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Affiliation(s)
- Karan Dua
- SUNY Downstate Medical Center, Brooklyn,
USA
| | | | | | - Joshua M. Abzug
- University of Maryland School of
Medicine, Baltimore, USA,Joshua M. Abzug, Department of Orthopaedics,
University of Maryland School of Medicine, 1 Texas Station Court, Suite 300,
Timonium, MD 21093, USA.
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26
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Adams AJ, O'Hara NN, Abzug JM, Aoyama JT, Ganley TJ, Carey JL, Cruz AI, Ellis HB, Fabricant PD, Green DW, Heyworth BE, Janicki JA, Kocher MS, Lawrence JTR, Lee RJ, McKay SD, Mistovich RJ, Patel NM, Polousky JD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Shea KG, Yen YM. Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model. Orthop J Sports Med 2019; 7:2325967119866162. [PMID: 31489334 PMCID: PMC6713965 DOI: 10.1177/2325967119866162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Tibial spine fractures, although relatively rare, account for a substantial
proportion of pediatric knee injuries with effusions and can have
significant complications. Meyers and McKeever type II fractures are
displaced anteriorly with an intact posterior hinge. Whether this subtype of
pediatric tibial spine fracture should be treated operatively or
nonoperatively remains controversial. Surgical delay is associated with an
increased risk of arthrofibrosis; thus, prompt treatment decision making is
imperative. Purpose: To assess for variability among pediatric orthopaedic surgeons when treating
pediatric type II tibial spine fractures. Study Design: Cross-sectional study. Methods: A discrete choice experiment was conducted to determine the patient and
injury attributes that influence the management choice. A convenience sample
of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including
physis-blinded radiographs displaying displaced fractures and a description
of the patient’s sex, age, mechanism of injury, and predominant sport.
Surgeons were asked whether they would treat the fracture operatively or
nonoperatively. A mixed-effects model was then used to determine the patient
attributes most likely to influence the surgeon’s decision, as well as
surgeon training background, years in practice, and risk-taking
behavior. Results: The majority of respondents selected operative treatment for 85% of the
presented cases. The degree of fracture displacement was the only attribute
significantly associated with treatment choice (P <
.001). Surgeons were 28% more likely to treat the fracture operatively with
each additional millimeter of displacement of fracture fragment. Over 64% of
surgeons chose to treat operatively when the fracture fragment was displaced
by ≥3.5 mm. Significant variation in surgeon’s propensity for operative
treatment of this fracture was observed (P = .01). Surgeon
training, years in practice, and risk-taking scores were not associated with
the respondent’s preference for surgical treatment. Conclusion: There was substantial variation among pediatric orthopaedic surgeons when
treating type II tibial spine fractures. The decision to operate was based
on the degree of fracture displacement. Identifying current treatment
preferences among surgeons given different patient factors can highlight
current variation in practice patterns and direct efforts toward promoting
the most optimal treatment strategies for controversial type II tibial spine
fractures.
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Affiliation(s)
- Alexander J Adams
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan N O'Hara
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua M Abzug
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julien T Aoyama
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Theodore J Ganley
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James L Carey
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I Cruz
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B Ellis
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D Fabricant
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W Green
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benton E Heyworth
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph A Janicki
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mininder S Kocher
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John T R Lawrence
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Jay Lee
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D McKay
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Justin Mistovich
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeraj M Patel
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John D Polousky
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jason T Rhodes
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brant C Sachleben
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - M Catherine Sargent
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A Schmale
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G Shea
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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27
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Mitchell SL, Sullivan BT, Ho CA, Abzug JM, Raad M, Sponseller PD. Pediatric Gartland Type-IV Supracondylar Humeral Fractures Have Substantial Overlap with Flexion-Type Fractures. J Bone Joint Surg Am 2019; 101:1351-1356. [PMID: 31393425 PMCID: PMC7406141 DOI: 10.2106/jbjs.18.01178] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Knowledge is limited about the diagnosis and treatment of modified Gartland type-IV supracondylar humeral fractures. We determined the prevalence of type-IV fractures, identified preoperative characteristics associated with these injuries, and assessed operative treatment characteristics. METHODS We retrospectively identified patients <16 years of age who underwent operative treatment of a supracondylar humeral fracture at 2 centers between 2008 and 2016. We compared patient, injury, and treatment characteristics between type-IV and type-III fracture groups (1:4, cases:controls). Preoperative radiographs were assessed by 4 pediatric orthopaedists blinded to fracture type. The odds of a fracture being type IV were assessed using univariate logistic regression for individual radiographic parameters. Significance was set at alpha = 0.05. RESULTS Type-IV fractures accounted for 39 (1.3%) of the supracondylar humeral fractures treated operatively during the study period. A type-IV fracture was associated with the following radiographic parameters: flexion angulation (odds ratio [OR] = 17; 95% confidence interval [CI] = 4.9 to 59), valgus angulation (OR = 5.6; 95% CI = 1.6 to 20), and lateral translation (OR = 4.1; 95% CI = 1.6 to 11) of the distal fragment; osseous apposition between the proximal and distal fragments (OR = 4.0; 95% CI = 1.8 to 9.0); and propagation of the fracture line toward the diaphysis of the proximal segment (OR = 9.2; 95% CI = 1.6 to 53). We found no significant differences in patient or injury characteristics between the groups. Compared with type-III fractures, type-IV fractures were treated more frequently with open reduction and percutaneous pinning (13% compared with 3.8%; p = 0.04) and were associated with longer mean operative time (82 ± 42 compared with 63 ± 28 minutes; p = 0.001). CONCLUSIONS We identified 5 preoperative radiographic parameters associated with greater odds of a supracondylar humeral fracture being type IV rather than type III. No patient or injury characteristic differed significantly between the groups. Substantial overlap likely exists between type-IV and flexion-type fractures. Type-IV fractures were associated with longer operative time and were treated with open reduction more frequently than were type-III fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stuart L. Mitchell
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian T. Sullivan
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine A. Ho
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas,Department of Orthopaedic Surgery, Children’s Medical Center, Dallas, Texas,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Joshua M. Abzug
- Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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28
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Abzug JM, Mehlman CT, Ying J. Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy. J Hand Surg Am 2019; 44:515.e1-515.e10. [PMID: 30266479 DOI: 10.1016/j.jhsa.2018.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/17/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury. METHODS Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors. RESULTS The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher. CONCLUSIONS The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Joshua M Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Timonium, MD.
| | - Charles T Mehlman
- Department of Orthopaedics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jun Ying
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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29
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Case AL, Hosseinzadeh P, Baldwin KD, Abzug JM. Hand Fractures in Children: When Do I Need to Start Thinking About Surgery? Instr Course Lect 2019; 68:415-426. [PMID: 32032048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Each year, a hand fracture is diagnosed in 24.2 of 100,000 children in Canada. Hand injuries are the most common fractures in children, making up approximately one fifth of all pediatric fractures. The incidence of hand fractures peaks between the ages of 10 and 14 years, with the highest frequencies observed among adolescent males. These increased frequencies coincide with the age at which most children begin playing contact sports, with sport-related injuries found to be the largest cause of adolescent fractures. The fifth digit is the most commonly injured digit, followed by the thumb. Phalangeal fractures constitute approximately 65% of pediatric hand fractures. Metacarpal fractures account for approximately 35% of pediatric and adolescent hand fractures, with 100 of every 100,000 children sustaining a fracture of the metacarpals. The decision to operate is related to many factors and depends on the age of the child and the location and nature of the fracture. The remodeling potential of pediatric bones factors largely into this decision because the phalangeal physis can contribute to bone growth and realignment via remodeling.
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30
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Dua K, Hosseinzadeh P, Baldwin KD, Abzug JM. Management of Pediatric Forearm Fractures After Failed Closed Reduction. Instr Course Lect 2019; 68:395-406. [PMID: 32032050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pediatric and adolescent forearm fractures account for nearly 40% of all fractures in childhood. The incidence of these fractures has increased over the past decade with a 10-fold increase in surgical intervention. A thorough physical examination of the upper extremity, with plain radiographs of the forearm, should be obtained to make the diagnosis. The primary modality of management for closed both-bone forearm fractures is a closed reduction if needed and long arm immobilization. Patients should be followed up weekly, for at least 3 weeks, to ensure maintenance of fracture alignment. Failure of closed management is a known complication of nonsurgical management, and providers should have a management algorithm to treat these patients. Re-manipulation and casting, or cast wedging, is warranted if the loss of reduction is noted early in the postreduction period. If closed reduction cannot be achieved, elastic stable intramedullary nailing is the management of choice with either single- or both-bone fixation. Potential complications of elastic stable intramedullary nailing include acute compartment syndrome, nonunion, dorsal radial sensory nerve neuritis, and extensor pollicis longus tendon rupture. In older children and adolescents with less remodeling potential, osteosynthesis with plate-and-screw fixation or hybrid fixation should be used.
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31
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Meyer Z, Devries C, Baldwin KD, Milbrandt TA, Abzug JM, Hosseinzadeh P. Tibial Shaft Fractures in Children: What to Do When Casting Fails? Instr Course Lect 2019; 68:473-480. [PMID: 32032061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Tibial shaft fractures in children can often be successfully managed with a well-molded cast that controls length, alignment, and rotation of the fracture. Acceptable alignment of tibial shaft fractures in children is less than 10° of coronal and sagittal angulation, 50% translation, and 10 mm of shortening. Fractures of the tibial shaft without an associated fibular shaft fracture may fall into varus malalignment despite initial adequate reduction and should be followed closely during the first 3 weeks after injury. Surgical treatment should be considered in adolescent patients and those with open fractures, comminuted fractures, and fractures that cannot be adequately reduced and stabilized with a cast. The predominant modes of surgical stabilization of tibial shaft fractures in children are external fixation or internal fixation with flexible intramedullary nails or via minimally invasive plate osteosynthesis; both methods have reliable results.
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32
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Baldwin KD, Hosseinzadeh P, Abzug JM, Milbrandt TA, Flynn JM. Femoral Shaft Fractures in Pediatric Patients: An Algorithm for Success. Instr Course Lect 2019; 68:453-462. [PMID: 32032062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Femoral shaft fractures in children are common injuries requiring orthopaedic intervention. Options for management have expanded in the past several decades to include an array of surgical and nonsurgical intervention. The American Academy of Orthopaedic Surgeons has produced practice guidelines for this injury to guide appropriate management. The age of the patient, the stability of the fracture, and the energy of the injury are factors when deciding the appropriate treatment for a patient. Orthopaedic surgeons should be familiar with the history of the management of pediatric femoral shaft fractures and understand the options available now.
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33
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Baldwin KD, Hosseinzadeh P, Milbrandt TA, Abzug JM. Monteggia Fracture-Dislocations in Children: History and Current Concepts and Management Schemes. Instr Course Lect 2019; 68:407-414. [PMID: 32032047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Since pediatric Monteggia fracture-dislocations were first described in 1814, they have been a complicated injury for orthopaedic surgeons to manage. These injuries typically consist of a fracture of the ulna with dislocation of the radial head. Unlike most pediatric injuries, Monteggia fracture-dislocations remodel very poorly, and the relationship between the radial head and the capitellum does not improve with time. As such, a more attentive approach is necessary. It is important for orthopaedic surgeons to be knowledgeable about the history of Monteggia fractures, common pathologic mechanisms, closed reduction techniques, surgical indications and methods, and outcomes, in addition to preferred management principles.
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34
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Shlykov MA, Milbrandt TA, Abzug JM, Baldwin KD, Hosseinzadeh P. Displaced Radial Neck Fractures: What Are My Options? Instr Course Lect 2019; 68:375-382. [PMID: 32032046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pediatric radial head and neck fractures are uncommon injuries. Fractures are classified using the Judet system based on fracture angulation and displacement. Judet type I and II fractures can be managed nonsurgically with a short course of immobilization in a cast or splint without closed reduction. Most of these patients have an excellent prognosis and functional outcomes. Judet type III and IV injuries, as well as injuries that demonstrate a mechanical block to motion, should be closed reduced with the patient under conscious sedation or general anesthesia. Patients who undergo an unsuccessful closed reduction require closed or open reduction in the operating room. Closed reduction methods include the push and lever techniques with the use of Kirschner wires or Steinmann pins or intramedullary nails. Percutaneous fixation with wires or pins is needed only if the fracture fragment is determined to be unstable, whereas nails are left in place and require a second surgery for removal. Both methods have similar outcomes and an overall positive prognosis for patients. Open reduction and internal fixation should be avoided if at all possible given the higher incidence of wide-ranging complications.
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35
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Young EY, Shlykov MA, Hosseinzadeh P, Abzug JM, Baldwin KD, Milbrandt TA. Fractures Around the Knee in Children. Instr Course Lect 2019; 68:463-472. [PMID: 32032063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Knee injuries are common in children, but epiphyseal and physeal injuries involving the distal femur and proximal tibia are relatively rare. This can make diagnosis and evaluation of pediatric knee injuries challenging. Pediatric knee physeal injuries can also be complicated by vascular injuries with potentially devastating consequences, and thus, a heightened suspicion for these injuries is indicated. Distal femoral and proximal tibial physeal injuries can be diagnosed with plain radiographs or with advanced imaging if the initial findings are equivocal. Physeal fractures of the distal femur and proximal tibia can be managed nonsurgically if nondisplaced or surgically with cannulated screw fixation or smooth, percutaneous pin fixation. Tibial tubercle injuries can have point tenderness or an extensor lag, are diagnosed with plain radiographs, and are often managed with physeal-sparing cannulated screw fixation. These injuries have an increased risk of compartment syndrome. Tibial eminence fractures are epiphyseal avulsion injuries caused by traction from the anterior cruciate ligament. Arthroscopic and open techniques for reduction and stable fixation yield good outcomes. Patellar sleeve injuries are often misdiagnosed and may require advanced imaging for diagnosis. They represent pediatric extensor mechanism injuries that often necessitate open reduction and fixation or patellar tendon advancement. Understanding the relevant anatomy, diagnosis, and management options can help guide the treating physician in the management of the fractures of the pediatric knee.
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36
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Devries C, Meyer Z, Abzug JM, Baldwin KD, Milbrandt TA, Hosseinzadeh P. Pediatric Ankle Fractures: When to Operate and When to Leave Alone? Instr Course Lect 2019; 68:481-488. [PMID: 32032053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Ankle fractures are a common pediatric orthopaedic injury and are the second most common site of physeal injury after the distal radius. Concerns regarding these injuries include the risk of premature physeal closure and intra-articular incongruence with subsequent degenerative changes. Salter-Harris type I and II injuries have high rates of premature physeal closure especially in those with a physeal gap greater than 3 mm and pronation-abduction injuries. The authors of this chapter recommend surgical management if acceptable alignment cannot be obtained with closed reduction. A residual physeal gap is not an appropriate sole indicator for surgical management. Salter-Harris type III and IV injuries also have high rates of premature physeal closure and can result in articular incongruence given their intra-articular nature. The authors of this chapter recommend surgical management of these fractures when intra-articular displacement is greater than 2 mm. Transitional fractures (ie, Tillaux and triplane) occur in older patients during distal tibial physeal closure. Fracture lines travel through the relatively weaker lateral tibial physis, which is the last to close in the transitional period. These intra-articular fractures with displacement greater than 2 mm should be managed surgically to anatomically reduce the articular surface and prevent early degenerative changes.
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37
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Huser AJ, Baldwin KD, Milbrandt TA, Abzug JM, Hosseinzadeh P. Lateral Condyle Fractures in Children. Instr Course Lect 2019; 68:367-374. [PMID: 32032044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Lateral condyle fractures are the second most common fracture sustained in the pediatric elbow. Several classification systems are used to describe these fractures. The more recently described classifications help guide management, which is based on the degree of displacement and stability of the fracture. The goal of management is to obtain reduction of the articular surface and fracture union using closed or open reduction and fixation with Kirschner wires or screws. Motion should improve after the surgery. Complications, such as osteonecrosis and nonunion, are rare, but the treating surgeon should watch for these conditions.
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38
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Scheiber AL, Guess AJ, Kaito T, Abzug JM, Enomoto-Iwamoto M, Leikin S, Iwamoto M, Otsuru S. Endoplasmic reticulum stress is induced in growth plate hypertrophic chondrocytes in G610C mouse model of osteogenesis imperfecta. Biochem Biophys Res Commun 2018; 509:235-240. [PMID: 30579604 DOI: 10.1016/j.bbrc.2018.12.111] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/14/2018] [Indexed: 12/21/2022]
Abstract
Osteogenesis imperfecta (OI) is a hereditary bone disorder most commonly caused by autosomal dominant mutations in genes encoding type I collagen. In addition to bone fragility, patients suffer from impaired longitudinal bone growth. It has been demonstrated that in OI, an accumulation of mutated type I collagen in the endoplasmic reticulum (ER) induces ER stress in osteoblasts, causing osteoblast dysfunction leading to bone fragility. We hypothesize that ER stress is also induced in the growth plate where bone growth is initiated, and examined a mouse model of dominant OI that carries a G610C mutation in the procollagen α2 chain. The results demonstrated that G610C OI mice had significantly shorter long bones with growth plate abnormalities including elongated total height and hypertrophic zone. Moreover, we found that mature hypertrophic chondrocytes expressed type I collagen and ER dilation was more pronounced compared to wild type littermates. The results from in vitro chondrocyte cultures demonstrated that the maturation of G610C OI hypertrophic chondrocytes was significantly suppressed and ER stress related genes were upregulated. Given that the alteration of hypertrophic chondrocyte activity often causes dwarfism, our findings suggest that hypertrophic chondrocyte dysfunction induced by ER stress may be an underlying cause of growth deficiency in G610C OI mice.
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Affiliation(s)
- Amanda L Scheiber
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Adam J Guess
- Center for Childhood Cancer and Blood Diseases, The Research Institute at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Joshua M Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Motomi Enomoto-Iwamoto
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Sergey Leikin
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, Bethesda, MD, 20892, USA
| | - Masahiro Iwamoto
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Satoru Otsuru
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA; Center for Childhood Cancer and Blood Diseases, The Research Institute at Nationwide Children's Hospital, Columbus, OH, 43205, USA.
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39
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Rosenberg RE, Abzug JM, Rappaport DI, Mazziotti MV, Shrader MW, Zipes D, Nwomeh B, McLeod L. Collaborations with Pediatric Hospitalists: National Surveys of Pediatric Surgeons and Orthopedic Surgeons. J Hosp Med 2018; 13:566-569. [PMID: 29408945 DOI: 10.12788/jhm.2921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To understand characteristics of pediatric hospitalist (PH) involvement in the care of children admitted to surgical services and explore surgeons' perspectives of PH effectiveness, we conducted a cross-sectional, web-based survey of pediatric surgical (PS) and pediatric orthopedic subspecialists (OS) from professional organizations. We used basic analyses to compare responses between the 2 surgical groups. The initial response rate was 48% (291/606) for PS and 59% (415/706) for OS. Among 185 PS and 212 OS unique programs, PH were routinely engaged (69% and 75%) in the care of surgical patients, particularly in patients with medical complexity (64% PS vs 81% OS; P = .003). PS and OS perceived positive PH impact on care coordination and comorbidity management but little on pain management or length of stay. OS were more likely than PS to view PH involvement positively (64% vs 42%; P < .001). Further research on care models, especially for children with medical complexity, is needed.
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Affiliation(s)
| | - Joshua M Abzug
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - David I Rappaport
- Nemours Alfred I. Dupont Hospital for Children, Wilmington, Delaware, USA
| | | | | | - David Zipes
- Peyton Manning Children's Hospital, Indianapolis, Indiana, USA
| | | | - Lisa McLeod
- Children's Hospital Colorado, Aurora, Colorado, USA
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40
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Abstract
HYPOTHESIS The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system. METHODS A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability. RESULTS Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III. SUMMARY There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures. LEVEL OF EVIDENCE Level III-diagnostic studies.
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Affiliation(s)
- Sophia Leung
- Department of Orthopaedics, University of Maryland School of Medicine, Timonium
| | - Ebrahim Paryavi
- Department of Orthopaedics, University of Maryland School of Medicine, Timonium
| | | | | | - Joshua M Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Timonium
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41
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Schwartz BS, Paryavi E, Eglseder WA, Pensy RA, Abzug JM. Brachial Artery Transection After a Closed Traumatic Isolated Medial Epicondyle Fracture in a Pediatric Patient: A Case Report. Hand (N Y) 2017; 12:NP127-NP131. [PMID: 28381125 PMCID: PMC5684950 DOI: 10.1177/1558944717702973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. METHODS A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. RESULTS A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. CONCLUSIONS Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.
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Affiliation(s)
| | | | | | | | - Joshua M. Abzug
- University of Maryland School of Medicine, Baltimore, USA,Joshua M. Abzug, Department of Orthopaedics, University of Maryland School of Medicine, 1 Texas Station, Suite 300, Timonium, MD 21093, USA.
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Abzug JM, Kozin SH, Waters PM. Open Glenohumeral Joint Reduction and Latissimus Dorsi and Teres Major Tendon Transfers for Infants and Children Following Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:30-36. [PMID: 28448306 DOI: 10.1097/bth.0000000000000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Glenohumeral dysplasia can occur in brachial plexus birth palsy due to an imbalance of muscle forces. Most commonly this occurs in C5-C6 injuries where the shoulder external rotators are weak compared with the shoulder internal rotators. Treatment of the dysplasia with open reduction of the glenohumeral joint in combination with rebalancing the muscles can improve the development of the joint. Furthermore, the tendon transfer can improve shoulder function by decreasing the internal rotation forces about the shoulder while increasing the external rotation forces. This paper describes the indications, contraindications, and technique of performing an open glenohumeral joint reduction and latissimus dorsi and teres major tendon transfers for brachial plexus birth palsy.
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Affiliation(s)
- Joshua M Abzug
- *Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD †Shriners Hospital for Children, Philadelphia, PA ‡Children's Hospital Boston, Boston, MA
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Micev AJ, Abzug JM, Osterman AL. Thoracic Outlet Syndrome: Getting It Right So You Don't Have to Do It Again. Instr Course Lect 2017; 66:103-113. [PMID: 28594492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thoracic outlet syndrome is a disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. The characteristics of thoracic outlet syndrome are highly variable. Objective tests, such as electrodiagnostic studies, are often unreliable in characterizing thoracic outlet syndrome. The existence of thoracic outlet syndrome as a discrete entity is controversial. Surgeons who accept the existence of thoracic outlet syndrome acknowledge that diagnosis is clinical. The variability and complexity of thoracic outlet syndrome lends itself to mistakes in both diagnosis and surgical treatment.
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Affiliation(s)
- Alan J Micev
- Fellow, The Philadelphia Hand Center, Thomas Jefferson University, Philadelphia, Pennsylvania
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Ting B, Sesko Bauer A, Abzug JM, Cornwall R, Wyrick TO, Bae DS. Pediatric Scaphoid Fractures. Instr Course Lect 2017; 66:429-436. [PMID: 28594519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Scaphoid fractures are the most common type of carpal injuries that occur in children and adolescents. The injury pattern seen in children and adolescents who have scaphoid fractures has recently shifted to resemble that of adults who have scaphoid fractures, with scaphoid waist fractures being the most common injury pattern. This shift has been attributed to increased body mass index in children and adolescents as well as more intense participation in extreme sports by both children and adolescents. The diagnosis of scaphoid fractures is based on both a clinical examination and radiographic fi ndings. If a scaphoid fracture is clinically suspected but initial radiographs are negative, cast immobilization followed by repeat imaging can lead to accurate diagnosis of the injury. MRI can aid in the diagnosis of a scaphoid injury in pediatric patients with incomplete ossifi cation of the scaphoid. Acute nondisplaced scaphoid fractures have a high rate of healing with cast immobilization; however, surgery should be considered in patients who have displaced scaphoid fractures with delayed presentation. In general, patients with scaphoid fractures who undergo appropriate treatment and achieve successful union have excellent long-term functional outcomes.
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Affiliation(s)
- Beverlie Ting
- Orthopaedic Surgeon, Seattle Hand Surgery Group, Seattle, Washington
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Dua K, Abzug JM, Sesko Bauer A, Cornwall R, Wyrick TO. Pediatric Distal Radius Fractures. Instr Course Lect 2017; 66:447-460. [PMID: 28594521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Distal radius fractures are the most common orthopaedic injury that occur in the pediatric population. The annual incidence of distal radius fractures has increased as a result of earlier participation in sporting activities, increased body mass index, and decreased bone mineral density. Most distal radius fractures are sustained after a fall onto an outstretched arm that results in axial compression on the extremity or from direct trauma to the extremity. Physeal fractures of the distal radius are described based on the Salter-Harris classification system. Extraphyseal fractures of the distal radius are described as incomplete or complete based on the amount of cortical involvement. A thorough physical examination of the upper extremity is necessary to rule out any associated injuries. PA and lateral radiographs of the wrist usually are sufficient to diagnose a distal radius fracture. The management of distal radius fractures is based on several factors, including patient age, fracture pattern, and the amount of growth remaining. Nonsurgical management is the most common treatment option for patients who have distal radius fractures because marked potential for remodeling exists. If substantial angulation or displacement is present, closed reduction maneuvers with or without percutaneous pinning should be performed. Patients with physeal fractures of the distal radius that may result in malunion who present more than 10 days postinjury should not undergo manipulation of any kind because of the increased risk for physeal arrest.
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Affiliation(s)
- Karan Dua
- Resident Physician, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
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Abzug JM, Dua K, Sesko Bauer A, Cornwall R, Wyrick TO. Pediatric Phalanx Fractures. Instr Course Lect 2017; 66:417-427. [PMID: 28594518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Phalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits in the United States for fractures. The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, which coincides with the time that most children begin playing contact sports. Younger children are more likely to sustain a phalangeal fracture in the home setting as a result of crush and laceration injuries. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which make fractures about the physis likely. A thorough physical examination is necessary to assess the digital cascade for signs of rotational deformity and/or coronal malalignment. Plain radiographs of the hand and digits are sufficient to confirm a diagnosis of a phalangeal fracture. The management of phalangeal fractures is based on the initial severity of the injury and depends on the success of closed reduction techniques. Nondisplaced phalanx fractures are managed with splint immobilization. Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. Unstable, displaced phalanx fractures require surgical management, preferably via closed reduction and percutaneous pinning.
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Affiliation(s)
- Joshua M Abzug
- Associate Professor, Departments of Orthopedics and Pediatrics, University of Maryland School of Medicine, Director, University of Maryland Brachial Plexus Clinic, Director of Pediatric Orthopedics, University of Maryland Medical Center, Deputy Surgeon-in-Chief, University of Maryland Children's Hospital, Baltimore, Maryland
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Dua K, Osterman AL, Abzug JM. Carpal Tunnel Syndrome: Initial Management and the Treatment of Recalcitrant Patients. Instr Course Lect 2017; 66:141-152. [PMID: 28594494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Carpal tunnel syndrome (CTS) is a focal compressive neuropathy of the median nerve at the level of the wrist. CTS is the most common type of compressive neuropathy that occurs in the upper extremity. Typically, patients with CTS have paresthesia, pain, and numbness in the radial three and one-half digits. Nighttime symptoms are more common earlier in the disease process, with daytime symptoms becoming more frequent as CTS progresses. Electrodiagnostic studies may be performed to confirm a diagnosis of CTS or to obtain a baseline before surgical treatment; however, electrodiagnostic studies may be normal in a subset of patients who have CTS. Patients who have mild CTS should undergo an initial trial of nonsurgical treatment that includes lifestyle modifications, nighttime splinting, and corticosteroid injections. Carpal tunnel release should be performed in patients in whom nonsurgical treatment fails and patients who have acute CTS secondary to infection or trauma or have advanced symptoms. Recalcitrant CTS, which may occur in as many as 25% of patients who undergo carpal tunnel release, most commonly results from an incomplete transverse carpal ligament release or an incorrect initial diagnosis. Patients with recurrent symptoms often have perineural fibrosis that tethers the median nerve.
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Affiliation(s)
- Karan Dua
- Resident Physician, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
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Neufeld ME, O'Hara NN, Zhan M, Zhai Y, Broekhuyse HM, Lefaivre KA, Abzug JM, Slobogean GP. Timing of Hip Fracture Surgery and 30-Day Outcomes. Orthopedics 2016; 39:361-368. [PMID: 27459143 DOI: 10.3928/01477447-20160719-07] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 06/01/2016] [Indexed: 02/03/2023]
Abstract
The goal of this study was to determine the proportion of patients admitted with a hip fracture to participating American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals who were treated within the United Kingdom's National Institute for Health and Care Excellence (NICE) time-to-hip-fracture-surgery benchmark. The secondary goals were to identify factors associated with missing the benchmark and to determine whether the benchmark was associated with improved 30-day patient outcomes. Patients aged 60 years or older who underwent hip fracture surgery between 2005 and 2013 were identified from the ACS-NSQIP database. Of the 26,066 patients who met the enrollment criteria, 71.4% were treated within the NICE benchmark. Many variables, including sex, race, procedure type, and hip fracture diagnosis, were statistically significant predictors of missing the benchmark (P<.001). Meeting the NICE benchmark was not associated with reductions in major complications (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83-1.05; P=.234); however, it was associated with reductions in 30-day mortality (OR, 0.88; 95% CI, 0.78-0.99; P=.028), minor complications (OR, 0.92; 95% CI, 0.84-0.995; P=.038), and postoperative length of stay (beta=-0.77; P<.001). Current practice at participating ACS-NSQIP hospitals is compatible with the NICE time-to-surgery benchmark. However, the findings highlight the importance of further prospective investigation to monitor the effect of early-treatment benchmarks on 30-day patient outcomes. [Orthopedics. 2016; 39(6):361-368.].
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Alexander C, Abzug JM, Johnson AJ, Pensy RA, Eglseder WA, Paryavi E. Motorcyclist's thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes. J Hand Surg Eur Vol 2016; 41:707-9. [PMID: 26642850 DOI: 10.1177/1753193415620186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/30/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to investigate motorcycle crash thumb injury patterns. We hypothesized that ulnar collateral ligament injuries at the thumb metacarpophalangeal joint would be most common and there would be a side predilection due to the clutch and brake positions. Motorcyclist admissions following injury between 2002 and 2013 were reviewed, and phalangeal and metacarpal injuries treated acutely identified. Demographics, injury, and treatment characteristics were recorded. Association between laterality and injury type was assessed. Of 128 patients, 59 underwent acute treatment for thumb injuries. Eleven patients sustained thumb ulnar collateral ligament injuries; 27 sustained thumb carpometacarpal injuries. Most carpometacarpal injuries were fracture-dislocations (19/27). Thumb carpometacarpal injuries had no overall side predilection; ulnar collateral ligament injuries occurred more on the right. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- C Alexander
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J M Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A J Johnson
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R A Pensy
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - W A Eglseder
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E Paryavi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
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