1
|
Greenhill DA, Riccio AI, Herman MJ. Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review. J Am Acad Orthop Surg 2024; 32:373-380. [PMID: 38639649 DOI: 10.5435/jaaos-d-23-00995] [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] [Received: 10/28/2023] [Accepted: 02/25/2024] [Indexed: 04/20/2024] Open
Abstract
Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.
Collapse
Affiliation(s)
- Dustin A Greenhill
- From the St. Luke's Children's Hospital at St. Luke's University Health Network, Bethlehem, PA (Greenhill), the Lewis Katz School of Medicine at Temple University, Philadelphia, PA (Greenhill), the Scottish Rite Hospital for Children, Dallas, TX (Riccio), the Department of Orthopedic Surgery, University of Texas Southwestern, Dallas, TX (Riccio), the St. Christopher's Hospital for Children, Philadelphia, PA (Herman); and the Drexel University College of Medicine, Philadelphia, PA (Herman)
| | | | | |
Collapse
|
2
|
Belthur MV, Ranade AS, Monsell F, Herman MJ. Controversies in the Management of Pediatric Musculoskeletal Infections: An International Viewpoint. Instr Course Lect 2024; 73:401-420. [PMID: 38090912] [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
Pediatric musculoskeletal infections (MSIs) are a major contributor to the global burden of musculoskeletal disease in children and young adults. If untreated, or treated inappropriately or inadequately, pediatric bone and joint infections can be fatal or result in morbidity that causes significant functional disabilities to the patient and economic burden to the family and the community at large. The past decade has witnessed many advances in this field with respect to early diagnosis, management, and prevention of complications. It is important to discuss the current controversies in the management of pediatric MSIs with an international perspective. This discussion should include the controversies associated with the early diagnosis and identification of pediatric MSI in diverse settings; the controversies involved in the nonsurgical and surgical management of acute pediatric MSIs; and the controversies associated with the management of sequelae of pediatric MSI.
Collapse
|
3
|
Gregory ME, Truelove A, Ahmad F, Corwin D, Tzimenatos L, Oglesbee SJ, Herman MJ, Leonard JC. Decision-making for pediatric cervical spine imaging after blunt trauma: Investigating team dynamics in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e13024. [PMID: 37600900 PMCID: PMC10432897 DOI: 10.1002/emp2.13024] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Cervical spine imaging decision-making for pediatric traumas is complex and multidisciplinary. Implementing a risk assessment tool has the potential to reduce variation in these decisions and unnecessary radiation exposure for pediatric patients. We sought to determine how emergency department-trauma team dynamics may affect implementation of such a tool. Methods We interviewed (pediatric and general emergency physicians, trauma surgeons, neurosurgeons, orthopedic surgeons and ED nurses at 21 hospitals to ascertain how team dynamics affect the pediatric cervical spine imaging decision-making process. Data were coded following a framework-driven deductive coding process and thematic analysis was used. Results Forty-eight physicians, advanced practice providers, and nurses from 21 hospitals (inclusive of three US regions, trauma levels I-III, and serving towns/cities of various population sizes) were interviewed. Overall, emergency physicians and trauma surgeons indicate being generally responsible for pediatric cervical spine imaging decisions. Conflict often occurs between these specialties due to differential weighting of concerns for missing an injury versus avoiding radiation exposure. Participants described a lack of trust and unclear roles regarding ownership for the final imaging decision. Nurses commonly described low psychological safety that prohibits them from participating in the decision-making process. Conclusions Implementation of a standardized risk assessment tool for cervical spine trauma imaging decisions must consider perspectives of both emergency medicine and trauma. Policies to define appropriate use of standardized tools within this team environment should be developed.
Collapse
Affiliation(s)
- Megan E. Gregory
- Department of Health Outcomes and Biomedical InformaticsUniversity of FloridaGainesvilleFloridaUSA
| | - Annie Truelove
- Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Fahd Ahmad
- Division of Emergency MedicineDepartment of PediatricsWashington University in St. Louis School of MedicineSt. LouisUSA
| | - Daniel Corwin
- Division of Emergency MedicineDepartment of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Leah Tzimenatos
- Department of Emergency MedicineUniversity of CaliforniaDavis School of MedicineSacramentoCaliforniaUSA
| | - Scott J. Oglesbee
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Martin J. Herman
- St. Christopher's Hospital for ChildrenPhiladelphiaPennsylvaniaUSA
| | - Julie C. Leonard
- Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
- Division of Emergency MedicineDepartment of PediatricsThe Ohio State University College of Medicine, and Nationwide Children's HospitalColumbusOhioUSA
| |
Collapse
|
4
|
Greenhill DA, Allred G, Feldman J, Herman MJ. Vascular Safe Zone During Percutaneous Pinning of the Distal Femur. J Pediatr Orthop 2022; 42:608-613. [PMID: 35998238 DOI: 10.1097/bpo.0000000000002248] [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: 02/07/2023]
Abstract
PURPOSE During percutaneous pinning of the pediatric distal femur, iatrogenic vascular damage in the medial thigh is a frequent concern. The proximity of a proximal-medial pin to these vessels has never been studied in children. This study describes a radiologic vascular safe zone that is easily visualized during surgery (wherein the superficial femoral vessels are safely posterior). METHODS Patients ≤16 years old with magnetic resonance imaging of one or both femora between 2005 and 2020 were retrospectively reviewed. The "at-risk level" (ARL) was defined as the distal-most axial image with a femoral vessel anterior to the posterior condylar axis. A standardized retrograde lateral-to-medial pin was templated. A correlation matrix and least squares regression identified age and physeal width (PW) as ideal independent variables. A vascular safe zone above the medial femoral condyle (MFC) was modeled as a multiple of PW (i.e. x*PW) and needed to satisfy 3 age-dependent criteria: (1) at the ARL, the pin is medial to the vessels, (2) the pin exits the medial thigh before the ARL, and (3) the chosen "vascular safe zone" (x*PW) is always distal to the ARL. RESULTS Forty-three patients averaging 7.1±3.9 (0.3-16) years old were included. Intra-Class correlation coefficients were excellent (0.92-0.98). All measurements strongly correlated with age ( r =0.76-0.92, P <0.001) and PW ( r =0.82-0.93, P <0.001). All patients satisfied criteria 1. Criteria 2 was satisfied in all patients ≥6 years old, 86% of children 4-5, and only 18% of children ≤3. In children >3 years old, the largest safe zone that satisfied criteria 3 was 2×PW. On average, the ARL was 2.5×PW (99% CI 2.3-2.7) above the MFC. The average ARL in children ≥6 years old was significantly higher than 2×PW (162 mm vs. 120 mm, P <0.001). CONCLUSION During passage of a distal femur pin into the medial thigh, children ≥6 years old have a vascular safe zone that extends 2×PW proximal to the MFC. Surgeons should be cautious with medial pin placement in children 4-5 years old and, if possible, avoid this technique in children ≤3. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Dustin A Greenhill
- Department of Orthopaedic Surgery, St. Luke's University Health Network, Bethlehem, PA
| | | | | | | |
Collapse
|
5
|
Mody KS, Henstenburg J, Herman MJ. The Health & Economic Disparities of Congenital Musculoskeletal Disease Worldwide: An Analysis of 25 Years (1992-2017). Glob Pediatr Health 2021; 8:2333794X21994998. [PMID: 33718527 PMCID: PMC7917875 DOI: 10.1177/2333794x21994998] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/21/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Large disparities exist in congenital musculoskeletal disease burden worldwide. The purpose of this study is to examine and quantify the health and economic disparities of congenital musculoskeletal disease by country income level from 1992 to 2017. Methods: The Global Burden of Disease database was queried for information on disease burden attributed to "congenital musculoskeletal and limb anomalies" from 1992 to 2017. Gross national income per capita was extracted from the World Bank website. Nonparametric Kruskal-Wallis tests were used to compare morbidity and mortality across years and income levels. The number of avertable DALYs was converted to an economic disparity using the human-capital and value of a statistical life approach. Results: From 1992 to 2017, a significant decrease in deaths/100 000 was observed only in upper-middle and high income countries. Northern Africa, the Middle East, and Eastern Europe were disproportionately affected. If the burden of disease in low- and middle- income countries (LMICs) was equivalent to that in high income countries (HICs), 10% of all DALYs and 70% of all deaths attributable to congenital musculoskeletal disease in LMICs could be averted. This equates to an economic disparity of about $2 billion to $3 billion (in 2020 $USD). Conclusion: Considerable inequity exists in the burden of congenital musculoskeletal disease worldwide and there has been no change over the last 25 years in total disease burden and geographical distribution. By reducing the disease burden in LMICs to rates found in HICs, a large proportion of the health and economic consequences could be averted.
Collapse
Affiliation(s)
- Kush S Mody
- Columbia Business School, New York, NY, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Martin J Herman
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| |
Collapse
|
6
|
Greenhill DA, Kozin SH, Kwon M, Herman MJ. Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients. JBJS Essent Surg Tech 2019; 9:ST-D-18-00107. [PMID: 32051776 DOI: 10.2106/jbjs.st.18.00107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures1. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI)2, lateral condylar fractures3, snapping medial triceps, and ulnar nerve instability4. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications. Description We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis. Alternatives Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition5. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut6-9, dome, 3-dimensional10, or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially)11,12. Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes13. Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old14. We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential. Rationale The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.
Collapse
Affiliation(s)
| | - Scott H Kozin
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Michael Kwon
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Martin J Herman
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, Mody KS, Leonard JC, Moront M, Brockmeyer DL, Anderson RCE, Alder AC, Anderson JT, Bernstein RM, Booth TN, Braga BP, Cahill PJ, Joglar JM, Martus JE, Nesiama JAO, Pahys JM, Rathjen KE, Riccio AI, Schulz JF, Stans AA, Shah MI, Warner WC, Yaszay B. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am 2019; 101:e1. [PMID: 30601421 DOI: 10.2106/jbjs.18.00217] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Martin J Herman
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Kristin O Brown
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | - Philip M Petrucelli
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Darshan J Parikh
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Kush S Mody
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew Moront
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Douglas L Brockmeyer
- Department of Neurological Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Richard C E Anderson
- Department of Neurosurgery, Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Adam C Alder
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - John T Anderson
- Department of Orthopedic Surgery, Children's Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Robert M Bernstein
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Timothy N Booth
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Bruno P Braga
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Patrick J Cahill
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeanne M Joglar
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jo-Ann O Nesiama
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Joshua M Pahys
- Shriners Hospitals for Children, Philadelphia, Pennsylvania
| | - Karl E Rathjen
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Anthony I Riccio
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Jacob F Schulz
- Department of Orthopedic Surgery, The Children's Hospital at Montefiore, Bronx, New York
| | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Manish I Shah
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - William C Warner
- Department of Orthopedic Surgery, University of Tennessee - Campbell Clinic and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital and University of California-San Diego Medical Center, San Diego, California
| |
Collapse
|
8
|
Anari JB, Hosseinzadeh P, Herman MJ, Eberson CP, Baldwin KD. Pediatric Polytrauma: What Is the Role of Damage Control Orthopaedics in the Pediatric Population? Instr Course Lect 2019; 68:337-346. [PMID: 32032040] [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
Severe pediatric trauma can be complicated for clinicians to manage because it is unusual and behaves somewhat differently from severe trauma in adults. Damage control orthopaedics is a philosophy that has gained traction in the past 30 years and has become standard in unstable adult trauma patients. Studies have failed to demonstrate clear utility for this approach in pediatric patients. Clinicians should understand the concepts of early total care and damage control orthopaedics for the patient with polytrauma, the physiologic factors associated with trauma in both children and adults who sustain severe trauma, and the role of early total care versus damage control orthopaedics in the treatment of the pediatric patient with polytrauma.
Collapse
|
9
|
Joshi T, Koder A, Herman MJ. Staying Out of Trouble: Complications of Supracondylar Humerus Fractures. Instr Course Lect 2019; 68:357-366. [PMID: 32032077] [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
Supracondylar fractures are among the most common fractures in children that require surgery. These fractures are also associated with some of the most serious complications of all fractures seen in children. Timely recognition and careful management can mitigate the potentially poor outcomes of these complications. Pin-site irritation and superficial infections are the most common complications seen. Cubitus varus remains another common complication, even with the use of closed reduction and pinning for management of most displaced fractures. Neurapraxias are seen in almost 10% of patients, with most resolving spontaneously. The worst complications are those that may be catastrophic for patients, causing substantial loss of function or even amputation of the limb; for example, vascular injury and compartment syndrome. Diagnosis and management of these complications should focus on strategies to ensure the best possible outcomes.
Collapse
|
10
|
Herman MJ, Ashok AP, Williams CS. Challenges in Pediatric Trauma: What We All Need to Know About Diaphyseal Forearm Fractures. Instr Course Lect 2019; 68:383-394. [PMID: 32032043] [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
Diaphyseal fractures of the radius and ulna are common injuries in children and often result from a fall on an outstretched hand. Fractures are classified by completeness, angular and rotational deformity, and displacement. The goal of management is to correct the deformity to the anatomic position or within acceptable alignment parameters as defined in the literature. This is primarily achieved by closed reduction and immobilization. Greenstick fractures are reduced by rotation of the palm toward the apex of the deformity. Complete fractures are reduced with sustained traction and manipulation. All fractures are immobilized in a cast, applied with the proper molding technique to ensure adequate stabilization, and maintained until healing is evident. Follow-up radiographs should be obtained weekly during the first 3 weeks after reduction to assess loss of reduction. Generally, postreduction malalignment greater than 20° is unacceptable, but these parameters vary based on age, fracture pattern, and the location and plane of angulation. Surgical intervention, with intramedullary nailing or plate fixation, is indicated for open fractures, for those with substantial soft-tissue injury, and when acceptable alignment cannot be achieved or maintained. Successful outcomes are seen in most forearm fractures in children, based on bone healing and restoration of functional forearm range of motion.
Collapse
|
11
|
Pokala NK, Silverio AL, Baldwin KD, Eberson CP, Herman MJ, Hosseinzadeh P. Fracture Remodeling in Children: Which Fractures Remodel and Which Do Not? Instr Course Lect 2019; 68:347-356. [PMID: 32032152] [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
Children have the capacity to remodel fractures because of their active physis and periosteum. Orthopaedic surgeons should be aware of the general guidelines that injuries in younger children, children with less displaced fractures, and children with injuries closer to the growth plate are likely to remodel better than in older children with injuries more distant from the growth plate and with more initial deformity. It is also important to recognize that deformity in the plane of motion is generally better tolerated than deformity outside the plane of motion. Rotational malalignment tends to remodel poorly if at all. When evaluating an injury, the physician should consider the growth potential of the physes in the area local to the injury and their likely contribution to the remodeling and healing process when deciding what management is right and what reduction is acceptable.
Collapse
|
12
|
Horn BD, Milbrandt TA, Young E, Herman MJ, Parikh D, Dasgupta R, Mody KS. Office Pediatric Orthopaedics for the General Orthopaedic Surgeon: Staying Current and Avoiding Mistakes. Instr Course Lect 2018; 67:605-628. [PMID: 31411444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pediatric and adolescent patients frequently are seen in the outpatient practices of general orthopaedic surgeons. Orthopaedic conditions may be a challenge to diagnose and manage in pediatric and adolescent patients. To avoid complications, general orthopaedic surgeons should understand current diagnostic techniques, evaluation methods, and treatment options for orthopaedic spine, hip, and lower extremity conditions that are common in pediatric and adolescent patients. General orthopaedic surgeons should understand the indications for surgical treatment in this patient population. In addition, general orthopaedic surgeons must understand methods to accurately, efficiently, and safely evaluate and manage orthopaedic conditions in pediatric and adolescent patients.
Collapse
Affiliation(s)
- Bernard D Horn
- Associate Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children�s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | | | | | | |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Varacallo MA, Wolf M, Herman MJ. Improving Orthopedic Resident Knowledge of Documentation, Coding, and Medicare Fraud. J Surg Educ 2017; 74:794-798. [PMID: 28258939 DOI: 10.1016/j.jsurg.2017.02.003] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/12/2016] [Accepted: 02/01/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Most residency programs still lack formal education and training on the basic clinical documentation and coding principles. Today's physicians are continuously being held to increasing standards for correct coding and documentation, yet little has changed in the residency training curricula to keep pace with these increasing standards. Although there are many barriers to implementing these topics formally, the main concern has been the lack of time and resources. Thus, simple models may have the best chance for success at widespread implementation. PURPOSE The first goal of the study was to assess a group of orthopedic residents' fund of knowledge regarding basic clinical documentation guidelines, coding principles, and their ability to appropriately identify cases of Medicare fraud. The second goal was to analyze a single, high-yield educational session's effect on overall resident knowledge acquisition and awareness of these concepts. SUBJECT SELECTION AND STUDY PROTOCOL Orthopedic residents belonging to 1 of 2 separate residency programs voluntarily and anonymously participated. All were asked to complete a baseline assessment examination, followed by attending a 45-minute lecture given by the same orthopedic faculty member who remained blinded to the test questions. Each resident then completed a postsession examination. Each resident was also asked to self-rate his or her documentation and coding level of comfort on a Likert scale (1-5). Statistical significance was set at p < 0.05. MAIN FINDINGS A total of 32 orthopedic residents were participated. Increasing postgraduate year-level of training correlated with higher Likert-scale ratings for self-perceived comfort levels with documentation and coding. However, the baseline examination scores were no different between senior and junior residents (p > 0.20). The high-yield teaching session significantly improved the average total examination scores at both sites (p < 0.01), with overall improvement being similar between the 2 groups (p > 0.10). PRINCIPAL CONCLUSIONS The current healthcare environment necessitates better physician awareness regarding clinical documentation guidelines and coding principles. Very few adjustments to incorporate these teachings have been made to most residency training curricula, and the lack of time and resources remains the concern of many surgical programs. We have demonstrated that orthopedic resident knowledge in these important areas drastically improves after a single, high-yield 45-minute teaching session.
Collapse
Affiliation(s)
| | - Michael Wolf
- Department of Orthopaedics, Drexel University, Philadelphia, Pennsylvania
| | - Martin J Herman
- Department of Orthopaedics, Drexel University, Philadelphia, Pennsylvania
| |
Collapse
|
15
|
Abstract
Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.
Collapse
Affiliation(s)
- Arianna Trionfo
- Department of Orthopaedic Surgery, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Priscilla K Cavanaugh
- Department of Orthopaedic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, USA
| | - Martin J Herman
- Department of Orthopaedic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, USA
| |
Collapse
|
16
|
Abstract
Limping is a symptom of varied diagnoses in children and adolescents and can present a difficult diagnostic challenge for primary care clinicians. A careful and systematic evaluation can shorten the long list of potential diagnoses to direct appropriate diagnostic tests to determine the cause of the problem. Trauma and infections are the most common causes of limping. Inflammatory conditions, developmental diagnoses,and overuse injuries are other causes. Although rare, malignancies such as osteosarcoma and blood cell cancers must also be considered as potential causes of limping in children and adolescents.• Limping presents a diagnostic challenge due to the number of possible causes.• On the basis of consensus, diagnostic laboratory tests that include complete blood count, erythrocyte sedimentation rate,C-reactive protein, and blood cultures should be ordered if suspicion is high for infectious etiology.• On the basis of consensus, orthopedic emergencies are vascular compromise, compartment syndrome, and open fractures.• On the basis of moderate evidence and consensus, compartment syndrome in children presents with the three "As" analgesia,anxiety, and agitation. (4)• On the basis of strong evidence and consensus, septic arthritis asa diagnosis increases with the number of Kocher criteria present(temperature >38.5°C, white blood cell count >12,000/mL[12109/L], erythrocyte sedimentation rate >40 mm/h, and inability to bear weight). (8)• On the basis of moderate evidence and consensus, laboratory studies are not always definitive for diagnosis of juvenile idiopathic arthritis. (13)• On the basis of consensus, it is always important to examine the joint above and the joint below the area of the chief compliant,specifically when looking at slipped capital femoral epiphysis and Legg-Calvé-Perthes disease.
Collapse
Affiliation(s)
- Martin J Herman
- Department of Orthopedic Surgery and Pediatrics, Drexel University College of Medicine, Philadelphia, PA
| | - Melissa Martinek
- St. Christopher's Hospital for Children/Philadelphia Shriner's Hospital, Philadelphia, PA
| |
Collapse
|
17
|
Kozin SH, Abzug JM, Safier S, Herman MJ. Complications of pediatric elbow dislocations and monteggia fracture-dislocations. Instr Course Lect 2015; 64:493-498. [PMID: 25745932] [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: 06/04/2023]
Abstract
Pediatric elbow dislocations and Monteggia lesions are prone to acute and chronic complications. A pediatric patient's cartilaginous and unossified distal humerus contributes to the risks of inaccurate diagnoses resulting from the misinterpretation of findings on plain radiographs. The debate continues regarding the amount of acceptable displacement for medial epicondyle fractures. In contrast, the radial head should always point directly to the capitellum. Chronic complications include instability and arthritis. Instability, which can be subtle and difficult to diagnose, can occur in the medial or the posterolateral direction, depending on the injured stabilizer. Restoration of stability remains the mainstay of treatment. Pediatric traumatic arthritis is extremely difficult to manage with surgery because of the limited number of reliable treatment options.
Collapse
Affiliation(s)
- Scott H Kozin
- Chief of Staff, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | | | | | | |
Collapse
|
18
|
Bassett WP, Safier S, Herman MJ, Kozin SH, Abzug JM. Complications of pediatric femoral shaft and distal physeal fractures. Instr Course Lect 2015; 64:461-470. [PMID: 25745929] [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: 06/04/2023]
Abstract
Fractures of the femoral shaft comprise about 1.6% of all bony injuries in children and are the most common pediatric orthopaedic injury that requires hospitalization. The treatment of femoral fractures in children is largely dependent on the child's age and size and takes into account multiple considerations: the child's weight, associated injuries, the fracture pattern, the mechanism of injury, institutional or surgeons' preferences, and economic and social concerns. In addition, during the past two decades, there has been a dramatic change favoring surgical fixation rather than casting because of the many advantages of fixation, including more rapid mobilization. The goal of treatment should be to ultimately obtain a healed fracture and avoid associated complications, such as nonunion or delayed union, angular or rotational deformity, unequal limb lengths, infection, neurovascular injury, disruption of the growth plate, muscle weakness, and/or compartment syndrome.
Collapse
Affiliation(s)
- William P Bassett
- Integrative Physiology, Medical Student, Department of Orthopedics, Drexel College of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | |
Collapse
|
19
|
Chia B, Kozin SH, Herman MJ, Safier S, Abzug JM. Complications of pediatric distal radius and forearm fractures. Instr Course Lect 2015; 64:499-507. [PMID: 25745933] [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: 06/04/2023]
Abstract
Distal radius and forearm fractures represent a large percentage of pediatric fractures. The most common mechanism of injury is a fall onto an outstretched arm, which can lead to substantial rotational displacement. If this rotational displacement is not adequately addressed, there will be resultant loss of forearm motion and subsequent limitations in performing the activities of daily living. Good initial reductions and proper casting techniques are necessary when treating distal radius and forearm fractures nonsurgically; however, maintaining an acceptable reduction is not always possible. Atraumatic reduction of a displaced physeal fracture should occur within 7 days of the injury. If an impending malunion presents at 2 weeks or later after injury, observation is warranted because of concerns about physeal arrest with repeated attempts at manipulation, and it should be followed by a later assessment of functional limitations. Pediatric patients and their parents have higher expectations for recovery, which has contributed to an increase in the surgical management of pediatric distal radius and forearm fractures. In addition, surgical interventions, such as intramedullary nailing, have their own associated complications.
Collapse
Affiliation(s)
- Benjamin Chia
- Resident, Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | | | | | | | | |
Collapse
|
20
|
Herman MJ, Martinek MA, Abzug JM. Complications of tibial eminence and diaphyseal fractures in children: prevention and treatment. Instr Course Lect 2015; 64:471-482. [PMID: 25745930] [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: 06/04/2023]
Abstract
Fractures of the tibial eminence and the diaphyseal tibia are common pediatric orthopaedic injuries. Although most tibial fractures can be treated nonsurgically, those that require surgical intervention may encounter specific complications. Surgical treatment of fractures of the tibial eminence may be complicated by failed fixation, knee joint stiffness, and arthrofibrosis of the knee, a complication rarely seen in children but occurring most frequently after tibial eminence injuries. Complications of healing after tibial fractures in pediatric patients are uncommon, although some tibial shaft fractures exhibit delayed union or nonunion, infection, and soft-tissue complications.
Collapse
Affiliation(s)
- Martin J Herman
- Associate Professor, Drexel University, Attending, Department of Orthopedic Surgery and Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | | | | |
Collapse
|
21
|
Meyer CL, Kozin SH, Herman MJ, Safier S, Abzug JM. Complications of pediatric supracondylar humeral fractures. Instr Course Lect 2015; 64:483-491. [PMID: 25745931] [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: 06/04/2023]
Abstract
Supracondylar humeral fractures are common in the pediatric population and can result in complications caused by both the injury itself and surgical or nonsurgical treatment. Neurologic complications are frequent, with the anterior interosseous nerve being the most common nerve affected. Vascular injuries, although less common, can result in long-term sequelae and should be recognized and treated promptly. Loss of reduction can occur with both surgical and nonsurgical treatment. Compartment syndrome and infection, although rare, require rapid recognition and treatment. It is important to be familiar with the potential complications surrounding the treatment of pediatric supracondylar humeral fractures to maximize outcomes and know when a referral may be warranted.
Collapse
Affiliation(s)
- Carissa L Meyer
- Resident, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, Maryland
| | | | | | | | | |
Collapse
|
22
|
Economedes DM, Abzug JM, Paryavi E, Herman MJ. Outcomes using titanium elastic nails for open and closed pediatric tibia fractures. Orthopedics 2014; 37:e619-24. [PMID: 24992056 DOI: 10.3928/01477447-20140626-52] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 08/14/2013] [Accepted: 12/27/2013] [Indexed: 02/03/2023]
Abstract
The authors conducted a retrospective review at their level I trauma center to assess the outcomes of closed vs open pediatric tibial fractures treated with titanium elastic nails. The study group included 38 pediatric patients (median age, 12 years) treated with titanium elastic nails for tibial fractures during a 5-year period. Patient demographics, closed or open injury, Gustilo-Anderson type for open fractures, fracture location, skeletal maturity, time to union, hospital length of stay, number of procedures performed per patient, and complications were recorded. The main outcome measures were time to union and complications. Average follow-up duration was 13 months. Mean time to union was 4 months for closed and 9 months for open fractures (P<.001). Average time to union for type IIIA and IIIB fractures was significantly increased (11 and 12 months, respectively; P=.02). Delayed union (>6 months postoperatively) occurred in 1 (6%) of 17 closed fractures compared with 11 (52%) of 21 open fractures. The average number of surgical procedures for closed fractures was fewer than for open fractures (2 vs 3 procedures, respectively; P=.03). Mean hospital length of stay was shorter for closed than open fractures (3 vs 6 days, respectively; P=.03). Two infections occurred in the open fracture group. Closed and open pediatric tibial shaft fractures can be successfully treated with titanium elastic nails. Open fractures treated with titanium elastic nails have a significantly longer time to union, require additional operative procedures, and result in longer hospital stays.
Collapse
|
23
|
Jakoi AM, Old AB, O'Neill CA, Stein BE, Stander EP, Rosenblatt J, Herman MJ. Influence of podiatry on orthopedic surgery at a level I trauma center. Orthopedics 2014; 37:e571-5. [PMID: 24972439 DOI: 10.3928/01477447-20140528-58] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 06/20/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.
Collapse
|
24
|
Morrison MJ, Herman MJ. Hip septic arthritis and other pediatric musculoskeletal infections in the era of methicillin-resistant Staphylococcus aureus. Instr Course Lect 2013; 62:405-414. [PMID: 23395045] [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: 06/01/2023]
Abstract
Pediatric musculoskeletal infections can cause devastating complications (including death) in this era of methicillin-resistant Staphylococcus aureus and other virulent bacterial strains. The complexity and severity of these infections require timely diagnosis and treatment. A thorough emergency department evaluation, diagnostic workup, and early surgical intervention can influence outcomes. Septic arthritis of the hip is best treated with open drainage and antibiotic therapy to avoid osteonecrosis of the hip and joint damage. Because of genetic changes and inducible resistance, methicillin-resistant Staphylococcus aureus causes more complex infections than in the past. Deep, soft-tissue abscesses; pyomyositis; osteomyelitis; and septic arthritis often occur concurrently, causing destruction of musculoskeletal tissue. Severe and life-threatening complications, such as septic emboli, deep venous thrombosis, and multiorgan system failure may result from these infections.
Collapse
Affiliation(s)
- Martin J Morrison
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | |
Collapse
|
25
|
Herman MJ, McCarthy J, Willis RB, Pizzutillo PD. Top 10 pediatric orthopaedic surgical emergencies: a case-based approach for the surgeon on call. Instr Course Lect 2011; 60:373-395. [PMID: 21553787] [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: 05/30/2023]
Abstract
Pediatric patients who require orthopaedic surgical emergency care are often treated by orthopaedic surgeons who primarily treat adult patients. Essential information is needed to safely evaluate and treat the most common surgical emergencies in pediatric patients, including hip fractures; supracondylar humeral, femoral, and tibial conditions of the hip (such as slipped capital femoral epiphysis and septic arthritis); and limb- and life-threatening pathologies, including compartment syndrome, the dysvascular limb, cervical spine trauma, and the polytraumatized child. To provide optimal care to pediatric patients, it is important to be aware of the key points in patient evaluation and surgical care as well as expected complications.
Collapse
Affiliation(s)
- Martin J Herman
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | | | | |
Collapse
|
26
|
Abstract
The care of the patient with scoliosis has a history extending back over two millennia with cast and brace treatment being a relatively recent endeavor, the modern era comprising just over half a century. Much of the previous literature provides a modest overview with emphasis on the history of the operative management. To better understand the current concepts of brace treatment of scoliosis, an appreciation of the history of bracing would be helpful. As such, we review the history of the treatment of scoliosis with an emphasis on modern brace treatment, primarily from a North American perspective. Our review utilizes consideration of historical texts as well as current treatises on the history of scoliosis and includes discussion of brace development with their proponents' rationale for why they work along with an appraisal of their clinical outcomes. We provide an overview of the current standards of care and the braces typically employed toward that standard including: the Milwaukee brace, the Wilmington brace, the Boston brace, the Charleston brace, the Providence brace and the SpineCor brace. Finally, we discuss future trends including improvements in methods of determining the critical period of peak growth velocity in children with scoliosis, the exciting promise of gene markers for progressive scoliosis and "internal bracing" options.
Collapse
Affiliation(s)
- Reginald S. Fayssoux
- Department of Orthopaedics, Drexel University College of Medicine, 245 North 15th Street, Philadelphia, PA 19102 USA
| | - Robert H. Cho
- Department of Orthopaedics, Drexel University College of Medicine, 245 North 15th Street, Philadelphia, PA 19102 USA
| | - Martin J. Herman
- Department of Orthopaedics, St Christopher’s Hospital for Children, East Erie Avenue & North Front Street, Philadelphia, PA 19134 USA
| |
Collapse
|
27
|
Affiliation(s)
- Jason A. Nydick
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, 4170 City Avenue, Philadelphia, PA 19131 USA
| | - Martin J. Herman
- Department of Orthopaedic Surgery, Drexel University College of Medicine and St. Christopher’s Hospital for Children, Philadelphia, PA USA
| | - Jean-Pierre de Chadarévian
- Department of Pathology and Laboratory Medicine, Drexel University College of Medicine and St. Christopher’s Hospital for Children, Philadelphia, PA USA
| |
Collapse
|
28
|
Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg Am 2009; 91:2188-93. [PMID: 19723996 DOI: 10.2106/jbjs.h.01316] [Citation(s) in RCA: 45] [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 The anterior humeral line is used to assess displacement and the adequacy of reduction of supracondylar humeral fractures in children. It is said to pass through the middle third of the capitellum in the elbow of a normal child. Few reports in the published literature have discussed this measurement, and the intra-rater and inter-rater reliability of the measurement is not known. The purposes of the present study were to define the position of the anterior humeral line in normal, skeletally immature elbows and to determine the intra-rater and inter-rater reliability of this parameter. METHODS On two occasions, three observers (a pediatric orthopaedic surgeon, a senior orthopaedic resident, and a senior medical student) recorded the location of the anterior humeral line as it passed through the capitellum as seen on the lateral radiographs of thirty normal elbows in children ranging in age from four months to three years and eleven months and thirty normal elbows in children ranging in age from four to nine years. For these measurements, the capitellum was divided into three regions: the anterior third, the middle third, and the posterior third. All observers received written instructions, and identical rulers were used to make the measurements. RESULTS Each observer made 120 measurements. Overall, the anterior humeral line passed through the anterior third of the capitellum in 31% of the elbows, the middle third in 52%, and the posterior third in 18%. In children younger than four years of age, the line passed nearly equally through either the anterior or middle third of the capitellum. In older children, the anterior humeral line passed through the middle third in 62% of the elbows. Overall, intra-rater reliability and inter-rater reliability were moderate to substantial. CONCLUSIONS The anterior humeral line passes through the middle third of the capitellum in the majority of normal children. In children younger than four years of age, it passes nearly equally through the anterior or middle third of the capitellum, whereas in older children it more consistently passes through the middle third of the capitellum. The surgeon must be aware of the variability of the location of the anterior humeral line with age when utilizing it to assess radiographs of the elbow in children after an injury or after the reduction of a displaced supracondylar fracture.
Collapse
Affiliation(s)
- Martin J Herman
- Department of Orthopaedics, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA.
| | | | | | | |
Collapse
|
29
|
de Chadarévian JP, Katsetos CD, Pascasio JM, Geller E, Herman MJ. Histological study of osteoid osteoma's blood supply. Pediatr Dev Pathol 2007; 10:358-68. [PMID: 17929985 DOI: 10.2350/06-07-0133.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [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] [Received: 01/19/2007] [Accepted: 01/22/2007] [Indexed: 11/20/2022]
Abstract
The osteoid osteoma is a painful lesion with a special predilection for the femur and tibia of young patients. Although the lesion has been described as richly innervated, its vascular supply has not been critically appraised to date in the pathology literature. To this end, we have undertaken a morphological study of 16 archival cases of osteoid osteoma, focusing primarily on the patterns of vascularization, utilizing traditional histological and immunohistochemical approaches. The study demonstrated that a prominent arterial and arteriolar blood supply was a constant finding within the various zones of soft tissues, skeletal muscle, and bone surrounding the nidus. It also showed that the caliber of the vessels underwent gradual attenuation throughout their centripetal course toward the nidus, where the vessels lost their muscularis as they merged into the capillary network of the nidus. Immunostaining with antibodies to neurofilament and S100 proteins revealed a pattern of innervation that was overall less exuberant than that described in some reports and that was virtually absent from the nidus. Taken together with data reported in the radiological literature, our findings lead us to wonder whether the osteoid osteoma may represent a response to the local stimulation of bony tissue by a primarily aberrant vasculature, a hypothesis that warrants further elucidation using state-of-the-art imaging approaches.
Collapse
Affiliation(s)
- Jean-Pierre de Chadarévian
- Department of Pathology and Laboratory Medicine, St. Christopher's Hospital for Children and Drexel University College of Medicine, Philadelphia, PA 19134, USA.
| | | | | | | | | |
Collapse
|
30
|
Abstract
Pediatric pelvic fractures account for only 1% to 2% of fractures seen by orthopaedic surgeons who treat children. They are typically associated with high-energy trauma, requiring a comprehensive workup for concomitant life-threatening injuries. Anteroposterior radiographs and rapid-sequence computed tomography are the standards of diagnostic testing to identify the fracture and recognize associated injuries. Treatment is individualized based on patient age, fracture classification, stability of the pelvic ring, extent of concomitant injuries, and hemodynamic stability of the patient. Most pelvic injuries in children are treated nonsurgically, with protected weight bearing and gradual return to activity. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intra-articular or triradiate cartilage fracture displacement >2 mm. To prevent limb-length discrepancies, external fixation is necessary for pelvic ring displacement >2 cm. Fractures involving immature triradiate cartilage may lead to growth disturbance of the acetabulum, resulting in acetabular dysplasia, hip subluxation, or hip joint incongruity. Osteonecrosis of the femoral head may develop after acetabular fractures associated with hip dislocation. Other complications include myositis ossificans and neurologic deficits secondary to sciatic, femoral, and/or lumbosacral plexus nerve injuries.
Collapse
Affiliation(s)
- Candice P Holden
- Department of Orthopedics, Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | | |
Collapse
|
31
|
Jacoby SM, Herman MJ, Morrison WB, Osterman AL. Pediatric Elbow Trauma: An Orthopaedic Perspective on the Importance of Radiographic Interpretation. Semin Musculoskelet Radiol 2007; 11:48-56. [PMID: 17665350 DOI: 10.1055/s-2007-984412] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [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: 01/29/2023]
Abstract
Radiographic interpretation of pediatric elbow trauma presents a daunting task for both the radiologist and treating orthopaedic surgeon. Proper radiographic diagnosis and appropriate intervention requires a thorough understanding and appreciation of developmental anatomy. As the pediatric elbow matures, it transitions from multiple cartilaginous anlagen through a predictable pattern of ossification and fusion. When children sustain trauma to the elbow, they may have a limited capacity to communicate specific complaints and are sometimes difficult to examine reliably. Furthermore, the presence of multiple growth centers, and their variability, makes radiographic evaluation of pediatric elbow injuries particularly challenging. These variables, coupled with the known adverse long-term sequelae of pediatric elbow trauma (painful nonunion, malunion, elbow stiffness, growth disturbance, etc.) highlight the importance of accurate radiographic interpretation, which facilitates appropriate treatment. By using an orderly, systematic approach based on well-defined anatomical relationships and accepted radiographic markers, the radiologist may effectively interpret and communicate pertinent findings to the treating orthopaedic surgeon. Furthermore, using common classification systems may facilitate interdisciplinary communication. Finally, it is crucial that caregivers of children consider the possibility of child abuse in suspect cases.
Collapse
Affiliation(s)
- Sidney M Jacoby
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
| | | | | | | |
Collapse
|
32
|
Abstract
Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (< or =50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw-laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.
Collapse
Affiliation(s)
- Emilie V Cheung
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | |
Collapse
|
33
|
Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg 2006; 14:417-24. [PMID: 16822889 DOI: 10.5435/00124635-200607000-00004] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [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] [Indexed: 02/01/2023] Open
Abstract
Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.
Collapse
Affiliation(s)
- Ralph Cavalier
- Summit Sports Medicine and Orthopaedic Surgery, Brunswick, GA, USA
| | | | | | | |
Collapse
|
34
|
Pizzutillo PD, Herman MJ. Musculoskeletal Concerns in the Young Athlete with Down Syndrome. OPER TECHN SPORT MED 2006. [DOI: 10.1053/j.otsm.2006.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
35
|
Abstract
This article presents a practical approach to management of displaced radius and ulna fractures in children and adolescents while addressing areas of controversy. Nonsurgical and surgical management are discussed. A technique for intramedullary fixation of the radius and ulna is presented in detail.
Collapse
Affiliation(s)
- Martin J Herman
- Department of Orthopedic Surgery, Division of Pediatric Orthopedics, Drexel University College of Medicine, St. Christopher's Hospital for Children, 3601 A Street, Philadelphia, PA 19134, USA.
| | | |
Collapse
|
36
|
Herman MJ. Cervical spine injuries in the pediatric and adolescent athlete. Instr Course Lect 2006; 55:641-6. [PMID: 16958497] [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: 05/11/2023]
Abstract
Injuries of the cervical spine in the pediatric and adolescent athlete are less common than other musculoskeletal injuries. Although many of these injuries are relatively minor, serious and potentially unstable or progressive spinal injury must be excluded. Important anatomic differences between the child younger than 10 years and older children and adolescents influence the types of injuries sustained and make assessment of the child's cervical spine sometimes difficult for practitioners accustomed to treating adolescent and adult athletes. Stable soft-tissue injuries of the cervical spine are the most common injuries that occur in all athletes. These injuries are responsive to symptomatic treatment and aggressive rehabilitation. Stingers are injuries of the brachial plexus and upper cervical roots that result from stretching or compressive forces associated with collision sports. Rapid return of sensory and motor dysfunction of a single upper extremity characterizes this entity; long-term disability is rare. Cervical cord neurapraxia (CCN) with transient quadriplegia is most commonly seen in football players. Most athletes fully recover. Cervical canal stenosis as defined by a Pavlov/Torg ratio of less than or equal to 0.8 is predictive of recurrent CCN. Young athletes sustain CCN secondary to hypermobility of the immature cervical spine. Return to play after these injuries is controversial. The athlete with Down syndrome and potential cervical hypermobility requires a careful cervical and neurologic evaluation prior to clearance for participation in sports.
Collapse
Affiliation(s)
- Martin J Herman
- Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| |
Collapse
|
37
|
Herman MJ. Torticollis in infants and children: common and unusual causes. Instr Course Lect 2006; 55:647-53. [PMID: 16958498] [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: 05/11/2023]
Abstract
Torticollis is a clinical symptom and sign characterized by a lateral head tilt and chin rotation toward the side opposite to the tilt. Many conditions cause torticollis. The differential diagnosis is different for infants than for children and adolescents. Congenital muscular torticollis associated with a contracture of the sternocleidomastoid muscle is the most common etiology of torticollis in infants. The condition of most infants with congenital muscular torticollis improves with a regimen of manual cervical stretching. Congenital anomalies of the occipital condyles and upper cervical spine must be ruled out before performing a release of the sternocleidomastoid muscle in a child who fails to improve with physical therapy. Unusual nonmuscular causes of torticollis in the infant also must be considered and include ocular torticollis caused by eye muscle weakness, Sandifer's syndrome resulting from gastroesophageal reflux, neural axis abnormalities, and benign paroxysmal torticollis. Torticollis in the older child is most frequently a manifestation of atlantoaxial rotatory displacement resulting from trauma or oropharyngeal inflammation (Grisel's syndrome). Retropharyngeal abscesses and pyogenic cervical spondylitis are unusual infectious causes of torticollis. Intermittent torticollis associated with headaches, vomiting, or neurologic symptoms may be caused by tumors of the posterior fossa. Benign and malignant neoplasms of the upper cervical spine are rare causes of torticollis in children. Torticollis resulting from cervical dystonia is also rare in children but may be seen in older adolescents.
Collapse
Affiliation(s)
- Martin J Herman
- Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| |
Collapse
|
38
|
|
39
|
Abstract
Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.
Collapse
Affiliation(s)
- Rakesh P Mashru
- Campbell Clinic, University of Tennessee College of Medicine, Memphis, TN, USA
| | | | | |
Collapse
|
40
|
Abstract
Spondylolysis and spondylolisthesis commonly are diagnosed in children and adolescents. The diagnostic workup and treatment plan vary widely among physicians. Although the orthopaedic literature is extensive on the topic, it is our opinion that a lack of clarity exists with regards to etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment. Important basic principles regarding spondylolysis and spondylolisthesis, with emphasis on clinical evaluation and nonsurgical treatment, serve as the basis for a new classification. We propose a new classification for pediatric spondylolysis and spondylolisthesis that is comprehensive, simple, and easily applied. This scheme is based on clinical presentation and spinal morphology and is more appropriate for the child and adolescent than the existing classification schemes of Wiltse-Newman and Marchetti-Bartolozzi. Algorithms for evaluation and treatment of spondylolysis and spondylolisthesis in children and adolescents, based on this new classification, are presented.
Collapse
Affiliation(s)
- Martin J Herman
- Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA.
| | | |
Collapse
|
41
|
Abstract
Evaluation of the child presenting with an irritable hip often requires aspiration of the hip. There are various methods for doing this procedure. We present a new technique for hip aspiration using high-resolution ultrasound imaging with color Doppler and a needle guide. This technique maximizes chances for a successful aspiration, minimizes risks to the child, avoids radiation exposure, and is easy to do and teach.
Collapse
MESH Headings
- Age Factors
- Arthritis, Infectious/complications
- Arthritis, Infectious/diagnostic imaging
- Arthritis, Infectious/physiopathology
- Biopsy, Needle/methods
- Child
- Diagnosis, Differential
- Equipment Design
- Exudates and Transudates/diagnostic imaging
- Hip Joint
- Humans
- Pain/etiology
- Pain/prevention & control
- Range of Motion, Articular
- Risk Factors
- Ultrasonography, Doppler, Color/instrumentation
- Ultrasonography, Doppler, Color/methods
- Ultrasonography, Interventional/instrumentation
- Ultrasonography, Interventional/methods
Collapse
Affiliation(s)
- Ralph Cavalier
- Department of Orthopaedic Surgery, Drexel University School of Medicine, Philadelphia, PA, USA
| | | | | | | |
Collapse
|
42
|
Abstract
Spondylolysis and spondylolisthesis are common causes of low back pain in the competitive athlete. Repetitive loading of the lumbar spine results in stress reactions and spondylytic defects of the pars interarticularis. Spondylolysis and lesser degrees of spondylolisthesis frequently respond to activity restrictions, bracing (in specific situations), and physiotherapy. Spinal fusion is indicated for spondylolysis and spondylolisthesis that remain painful despite nonoperative measures and progressive, high-grade spondylolisthesis. Return-to-play guidelines are made for each athlete individually based on his or her specific diagnosis, response to treatment, and sporting activity.
Collapse
Affiliation(s)
- Martin J Herman
- St. Christopher Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA.
| | | | | |
Collapse
|
43
|
Spiegel DA, Herman MJ, Bowe JA, Javidian P, Epstein RE. Popliteal mass in a 3-year-old boy. Clin Orthop Relat Res 2003:363-70. [PMID: 12782897 DOI: 10.1097/01.blo.0000072045.81222.a5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- David A Spiegel
- Shriner's Hospitals for Children/Twin Cities, Minneapolis, MN 55414, USA.
| | | | | | | | | |
Collapse
|
44
|
Horn BD, Herman MJ, Crisci K, Pizzutillo PD, MacEwen GD. Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability. J Pediatr Orthop 2002; 22:8-11. [PMID: 11744845] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement < or =3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.
Collapse
Affiliation(s)
- B David Horn
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA.
| | | | | | | | | |
Collapse
|
45
|
Abstract
Stubbing injuries to the great toe can be a cause of occult open fractures and osteomyelitis. Five such patients were identified after conducting a retrospective review of injuries to the hallux between January 1998 and December 1998. The study was conducted to draw attention to the association between this trivial trauma and its possible complications. All five children had open fractures of the distal phalanx of the great toe. Osteomyelitis did not develop in the children whose injuries were recognized early and who were treated with antibiotics. However, three children with delayed diagnoses and treatment developed osteomyelitis. At a mean follow-up of 10 months (range, 9-11) after injury, all five fractures had healed with no active signs of infection. Two of these children experienced a partial growth arrest and two experienced a full growth arrest of the distal phalanx of the great toe, the significance of which is yet unknown. Clinical signs such as bleeding from the eponychium and a laceration proximal to the nail bed should alert physicians to the presence of a possible open fracture. Early detection and treatment of these injuries may reduce or eliminate hospital stays and prolonged intravenous antibiotic treatment for osteomyelitis.
Collapse
Affiliation(s)
- D R Kensinger
- Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | | | | | | |
Collapse
|
46
|
Abstract
Care of children with disorders of the cervical spine requires an understanding of the anatomic and biologic features particular to the developing pediatric spine. Congenital and developmental alterations further complicate evaluation and treatment of children. Basic knowledge of pediatric cervical spine disorders in Down syndrome, Klippel-Feil syndrome, osteochondrodysplasias, mucopolysaccharidoses, and post-traumatic instability is essential for all orthopedic surgeons. Thorough patient evaluation and appropriate early management may prevent potentially serious neurologic injury and other complications related to cervical spine pathology.
Collapse
Affiliation(s)
- M J Herman
- Orthopaedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134, USA
| | | |
Collapse
|
47
|
Affiliation(s)
- M J Herman
- St Christopher's Hospital for Children, Orthopedic Center for Children, Philadelphia, PA 19134-1095, USA
| | | |
Collapse
|
48
|
Herman MJ, Pizzutillo PD. Physeal fractures aboutthe ankle and osteochondral lesions of the talus in the skeletally immature athlete. OPER TECHN SPORT MED 1998. [DOI: 10.1016/s1060-1872(98)80006-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
49
|
Affiliation(s)
- J J Myer
- Orthopaedic Center for Children, St Christopher's Hospital for Children, Philadelphia, PA 19134-1095, USA
| | | | | |
Collapse
|
50
|
Herman MJ. Hospital finance. J Health Care Finance 1998; 24:22-26. [PMID: 9612734] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
This article summarizes key areas of focus for the analysis of risk in the hospital segment of the health care industry. The article is written from a commercial bank lending perspective. Both for-profit (C-corporations) and 501 (c)(3) not-for-profit segments are addressed.
Collapse
|