Treatment of proximal tibial buckle fractures: removable knee immobilizer versus long leg cast

The purpose of this study was to compare outcomes and management of patients with buckle fractures of the proximal tibia treated with either a knee immobilizer or a long leg cast (LLC). A retrospective review was performed of pediatric patients with a buckle fracture of the proximal tibia over a 5-year period. Two cohorts were included, those treated with a LLC versus a removable knee immobilizer. Data collected included immobilization type, fracture laterality, length of immobilization, number of clinic visits, fracture displacement, and complications. Differences in complications and management between the cohorts were evaluated. In total, 224 patients met inclusion criteria (58% female, mean age 3.1 years ± 1.7 years). Of these patients, 187 patients (83.5%) were treated with a LLC. No patients in either group were found to have interval fracture displacement during treatment. Seven patients (3.1%) demonstrated skin complications, all in the LLC cohort. Mean length of immobilization was shorter for those treated in a knee immobilizer at 25.9 days versus 27.9 days for the LLC cohort (P = 0.024). Total number of clinic visits was also less at 2.2 (SD ± 0.4 days) for the knee immobilizer and 2.6 (SD ± 0.7 days) for the LLC (P = 0.001) cohorts. Pediatric patients with proximal tibial buckle fractures can be safely managed with a knee immobilizer. This treatment method is associated with a shorter duration of immobilization and fewer clinic visits without incidence of fracture displacement. In addition, knee immobilizers can lessen skin issues associated with cast immobilization and cast-related office visits. This is a Level III evidence, retrospective comparative study.

Rotator cuff tendinopathy: magnitude of incapability is associated with greater symptoms of depression rather than pathology severity

BACKGROUND

Population-based studies have established that rotator cuff tendinopathy develops in most persons during their lifetimes, it is often accommodated, and there is limited correspondence between symptom intensity and pathology severity. To test the relationship between effective accommodation and mental health on its continuum, we studied the relative association of magnitude of capability with symptoms of anxiety or depression compared with quantifications of rotator cuff pathology such as defect size, degree of retraction, and muscle atrophy among patients presenting for specialty care.

METHODS

We analyzed a retrospective cohort of 71 adults seeking specialty care for symptoms of rotator cuff tendinopathy who underwent a recent magnetic resonance imaging scan of the shoulder and completed the following questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health questionnaire (a measure of symptom intensity and magnitude of capability, consisting of mental and physical health subscores), Generalized Anxiety Disorder questionnaire (measuring symptoms of anxiety), and Patient Health Questionnaire (measuring symptoms of depression). Two independent reviewers measured the sagittal length of the rotator cuff defect and tendon retraction in millimeters on magnetic resonance imaging scans (excellent reliability) and rated rotator cuff muscle atrophy and fatty infiltration (more limited reliability), and we used the average measurement or rating for each patient. Multivariable statistical models were used to identify factors associated with the PROMIS Global Health score and mental and physical health subscores.

RESULTS

Accounting for potential confounding in multivariable analysis, lower PROMIS Global Health total scores and physical health subscale scores were independently associated with greater symptoms of depression but not with measures of pathology. Lower PROMIS mental health subscale scores were independently associated with greater symptoms of anxiety and greater muscle atrophy.

CONCLUSIONS

The observation that magnitude of incapability among patients seeking care for symptoms of rotator cuff pathology is associated with symptoms of depression but not with measures of the severity of the rotator cuff pathology suggests that treatment strategies for patients who seek care for symptoms of rotator cuff tendinopathy may be incomplete if they do not anticipate and address mental health.

Persistent Shoulder Pain After Vaccine Administration Is Associated with Common Incidental Pathology: A Systematic Review

BACKGROUND

Claims of shoulder injury now account for half of all claims to the Vaccine Injury Compensation Program. Reports from databases of claims or potential adverse events note a relatively high mean age and high prevalences of rotator cuff tendinopathy and adhesive capsulitis-common shoulder problems that might be incidental to vaccination. Published case reports provide much more detail about individual patients than is available in databases. A review of published cases provides an opportunity for more detailed review of symptoms, diagnoses, pathology, treatment, and prognosis. Such a review can better assess the relative likelihood that pathologies associated with new persistent shoulder symptoms after vaccination are coincidental or unique to and caused by vaccine.

QUESTIONS/PURPOSES

Regarding published case reports addressing persistent shoulder pain after vaccination: (1) In what proportion of patients was a specific diagnosis made? (2) What diagnoses were most common? (3) Among patients treated nonsurgically, what proportion resolved, and over what time span did they resolve?

METHODS

In August 2020, we searched PubMed and Embase between 2006 and 2020 using the following search strategy: Search 1: (shoulder dysfunction OR shoulder pain OR shoulder bursitis OR rotator cuff tendonitis OR adhesive capsulitis OR glenohumeral arthritis AND [vaccine OR vaccination OR immunization]); Search 2: (shoulder injury related to vaccine administration or SIRVA). The search was supplemented by reviewing reference lists of identified studies. Inclusion criteria were any detailed report of three or fewer cases involving shoulder pain after vaccine administration. Twenty published reports of 29 patients were identified and assessed by two reviewers independently. One reported glenohumeral joint infection was excluded because the relationship between this type of relatively uncommon, discrete diagnosis and vaccination raises different considerations. We assumed a high risk of bias, although we are not aware of bias assessment tool for case reports. We recorded and summarized patient demographics, symptoms, examination and imaging findings, surgery findings, diagnoses, treatments, and outcomes. Seventy-five percent (21 of 28) of patients were women, with a mean age of 54 ± 19 years. In search of an underlying pathology, at least one diagnostic study was performed in 82% (23 of 28) of patients including radiographs in seven, ultrasound in seven, and MRI in 16 patients (some patients underwent more than one type of imaging). We distinguished specific pathophysiological diagnosis from shoulder pain and stiffness, counted the most common diagnoses among patients a specific diagnosis, and tracked symptom resolution among patients treated nonoperatively.

RESULTS

A specific diagnosis was made in 57% (16 of 28) of patients. Twelve patients had pain and limitation of motion due to pain but no specific pathological diagnosis. The most common specific diagnoses were rotator cuff tendinopathy (9 of 16) and adhesive capsulitis (4 of 16). Less common specific diagnoses included rotator cuff arthropathy (and rheumatoid arthritis) and suspected septic arthritis with nonspecific synovitis on arthroscopy. One patient had transient MRI signal change in the humeral head, which was interpreted as osteonecrosis that resolved in a manner not typical for that diagnosis. Of the 17 patients treated nonsurgically, 15 reported resolution, and two had incomplete symptom resolution with the mean 6-month evaluation period.

CONCLUSION

The observation that persistent shoulder pain after vaccination overlaps with common shoulder pathology-both in large databases as well as in more detailed reports of specific patients as analyzed in this review-establishes a high probability of a coincidental rather than a causal association. In the absence of high-quality experimental evidence of vaccine-specific shoulder pathology, in our opinion, it seems safest and healthiest to assume that perceived shoulder injury related to vaccine administration (SIRVA) is due to misinterpretation of new symptoms from established pathology rather than a new, vaccine-specific pathology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.