MRI of the Spine in Patients who Toe Walk: Is There a Role?

BACKGROUND

Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings.

METHODS

A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking.

RESULTS

The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum.

CONCLUSIONS

Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

The Healthcare Experience of Autistic Patients in Orthopaedic Surgery and Closely Related Fields: A Scoping Review

Orthopaedic and related care has the potential to present unique obstacles for patients with a range of autism manifestations. In this review, we aim to describe and analyze the literature on autistic patients' experience within orthopaedics and closely related fields. This literature search utilized the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases. Three major concepts were built into the search terms: (1) patients on the autism spectrum; (2) patient experience; and (3) movement sciences, including orthopaedics, physical medicine and rehabilitation (PM&R), occupational therapy (OT), and physical therapy (PT). Our search yielded 35 topical publications, with the major topic areas addressed as follows: (1) clinical and perioperative management, (2) therapy interventions, (3) participation in exercise and social play, (4) sensory management and accommodations, (5) caregiver/parent training and involvement in care, (6) healthcare needs and barriers to care, and (7) utilization of technology. In the current literature, there are no studies that attempt to directly assess autistic patient experience with care practices and clinical environments in orthopaedics. Rigorous, direct examination of the experience of autistic patients within clinical orthopaedic settings is urgently needed to address this gap.

Anxiety surrounding supracondylar humerus pin removal in children

PURPOSE

The purpose of this study was to quantify the anxiety experienced by patients undergoing pin removal in clinic following closed reduction and percutaneous pinning for supracondylar humerus fractures.

METHODS

We prospectively enrolled 53 patients (3-8 years) treated for supracondylar humerus fracture with closed reduction and percutaneous pinning between July 2018 and February 2020. Demographic and injury data were recorded. Heart rate and the Face, Legs, Activity, Cry, and Consolability scale were measured immediately before pin removal and after pin removal, and crossover control values were obtained at the subsequent follow-up clinic visit.

RESULTS

All patients experienced anxiety immediately prior to pin removal (95% confidence interval, 94%-100%) with a median Face, Legs, Activity, Cry, and Consolability score of 7 (interquartile range, 6-8). In addition, 98% of subjects experienced an elevated heart rate (95% confidence interval, 88%-100%). Patients experienced a median 73% reduction in Face, Legs, Activity, Cry, and Consolability score and mean 21% reduction in heart rate from prior to pin removal to after pin removal (p < 0.001). All 45 patients who completed their follow-up visit had a control Face, Legs, Activity, Cry, and Consolability score of 0 and a mean control heart rate of 89.7 bpm. Twenty-five of these 45 subjects (56%) had an elevated control heart rate for their age and sex. Mean heart rate prior to pin removal was 36% higher than control heart rate. There were no sex differences detected in Face, Legs, Activity, Cry, and Consolability scores or heart rate.

CONCLUSIONS

Pediatric patients experience high levels of anxiety when undergoing pin removal following closed reduction and percutaneous pinning for supracondylar humerus fractures. This is an area of clinical practice where intervention may be warranted to decrease patient anxiety.

LEVEL OF EVIDENCE

II.

Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi

Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting.

Methods

We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment.

Results

We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.

Conclusions

Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction and Internal Fixation of Pediatric Medial Epicondylar Humeral Fractures in the Prone Position

BACKGROUND

Fracture of the medial epicondyle is a common pediatric injury, with an estimated annual incidence of 40 to 60 per 100,000 people per year^1-3. Medial epicondylar fractures are associated with elbow dislocation in about 60% of cases, and ulnar nerve dysfunction is reported to occur nearly 10% of the time^2,4. No standard of care for medial epicondylar fracture exists, as similar outcomes have been demonstrated in observational studies with both operative and nonoperative treatment^5,6. Increasingly, however, these injuries are being treated with surgical intervention, which in most cases consists of a single screw affixing the osseous piece back to its donor site on the humerus^7-9. There is broad consensus on the absolute indications for operative treatment, including an open fracture and an incarcerated epicondylar fragment^1,10-13. The relative indications are more controversial and include ulnar nerve dysfunction, elbow instability, increased fragment displacement, and high-level throwing or upper-extremity weight-bearing athletes^2,9,14-16.

DESCRIPTION

The patient is placed in the prone position with the operative arm on a radiolucent arm board. A milking maneuver with an Esmarch bandage is utilized. A posteromedial incision is made over the medial epicondyle. The ulnar nerve is protected posteriorly. The fracture is easily reduced under minimal tension, and then 1 or 2 guidewires from the 4.0-mm cannulated screw kit are placed to fix the fragment. The central guidewire is overreamed, and then a partially threaded 4.0-mm screw is placed in a relative posterior-to-anterior trajectory within the medial column of the elbow.

ALTERNATIVES

Nonoperative treatment includes immobilization in a long arm cast until fragment healing. Complications associated with nonoperative treatment include nonunion and late instability. Supine positioning is a reasonable alternative to the prone position described here. In that case, the fracture is fixed with the arm in external rotation of the shoulder and with the elbow extended.

RATIONALE

Prone positioning for operative treatment of medial epicondylar fractures is preferred because the tension from the flexor pronator mass associated with supine positioning is negated, facilitating an easier fracture reduction and improved anatomic reduction.

EXPECTED OUTCOMES

To our knowledge, there are currently no Level-I or Level-II prospective studies reporting on the outcomes of operative versus nonoperative treatment of medial epicondylar fractures. A systematic review of retrospective results suggested no difference in pain or clinical outcomes, but >9-times greater odds of union with operative treatment^5,6. Expectations following operative treatment of a medial epicondylar fracture have been explored in multiple studies. Generally, return to full levels of activity and near-normal range of motion of the elbow have been demonstrated by most. Minor rates of range-of-motion limitation, including extension deficit (4% with deficit up to 20°) are reported in some studies⁸. In the setting of preoperative instability, the expectation is that elbow stability will be achieved by operative treatment^7,8.

IMPORTANT TIPS

Perform and document an accurate preoperative neurovascular examination of the arm.Test the shoulder in internal rotation prior to prone positioning.Protect the ulnar nerve during surgical fixation and drilling.Confirm that the screw trajectory is relatively posterior to anterior and only in the medial column of the elbow.

Osteoid Osteoma About the Hip in Children and Adolescents

BACKGROUND

The etiology of hip pain in pediatric and adolescent patients can be unclear. Osteoid osteoma (OO) about the hip in children has only been described in case reports or small studies. The present study assessed the clinical presentation and diagnostic course, imaging, and treatment approaches in a large cohort of pediatric cases of OO about the hip.

METHODS

Medical record and imaging results were reviewed for all cases of OO identified within or around the hip joint in patients <20 years old between January 1, 2003, and December 31, 2015, at a tertiary-care pediatric center. Demographic, clinical, and radiographic data were analyzed.

RESULTS

Fifty children and adolescents (52% female; mean age, 12.4 years; age range, 3 to 19 years) were identified. Night pain (90%) and symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs) (88%) were common clinical findings. Sclerosis/cortical thickening was visible in 58% of radiographs, although a radiolucent nidus was visible in only 42%. Diagnostic imaging findings included perilesional edema and a radiolucent nidus on 100% of available magnetic resonance imaging (MRI) and computed tomography (CT) scans, respectively. Initial alternative diagnoses were given in 23 cases (46%), the most common of which was femoroacetabular impingement (FAI). Delay in diagnosis of >6 months occurred in 43% of patients. Three patients underwent operative procedures for other hip diagnoses, but all had persistent postoperative pain until the OO was treated. Of the 41 patients (82%) who ultimately underwent radiofrequency ablation (RFA), 38 (93%) achieved complete post-RFA symptom resolution.

CONCLUSIONS

Initial misdiagnosis, the most common of which was FAI, and delayed correct diagnosis are common in pediatric OO about the hip. Presenting complaints were variable and nonspecific MRI findings were frequent. Night pain and relief with NSAIDs were present in the vast majority of cases. CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as FAI, OO should not be overlooked in the differential diagnosis.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti

Purpose

The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.

Methods

We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.

Results

Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).

Conclusions

Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

[Do thoracic surgery patients always need a postoperative chest X-ray?]

INTRODUCTION

Following surgical procedures in thoracic surgery a chest X-ray is routinely performed and its necessity is rarely questioned. However, there are differences in the time frame of such radiological procedures. Especially after minor procedures such as mediastinoscopy there is a wide variation from a chest X-ray immediately after surgical intervention to an image only on the following day. Also, in some hospitals patients undergo only clinical but no radiological examination. No recommendations are available in the literature.

AIM AND METHOD

Following video-mediastinoscopy with good visualisation of all structures it appeared that a chest X-ray could be waived. 95 consecutive patients were prospectively randomised into two groups, either receiving chest X-ray four hours postoperatively or no chest X-ray. All patients were clinically examined on the evening of the day of mediastinoscopy.

RESULTS

48 % of the patients had a chest X-ray, 52 % did not and underwent only clinical examination. No surgical revision was necessary in either group, no difference in therapeutic consequences was noted. As a result we discontinued chest X-rays after mediastinoscopy.

DISCUSSION

There are only sparse data concerning postoperative chest X-rays in thoracic surgery patients. In a study on children and young adults undergoing a Nuss procedure routine radiological examination was substituted by clinical indication resulting in a lower rate of thoracic drain placement. A chest X-ray to document the location of the metal bar prior to discharge was felt to be sufficient. In patients undergoing cardiac procedures daily routine chest X-rays on the intensive care ward were replaced by on-demand X-ray in a study without any change in length of stay, readmission or mortality. The same was found for chest X-rays following drain removal in cardiac patients: routine radiological examination seems not to be indicated. As a consequence of our own observational study on mediastinoscopy we have discontinued postoperative X-ray as the patients are examined clinically. All other patients undergoing thoracic surgery procedures who are observed in the intensive care unit receive the first chest X-ray in the morning following surgery. Only if complete expansion of the lung is warranted (pleurodesis, pneumothorax) an X-ray is performed on the day of surgery.

Quantitative X-ray photoelectron spectroscopy and time-of-flight secondary ion mass spectrometry characterization of the components in DNA

The great diversity of techniques to synthesize and use DNA microarrays has made them extremely flexible for a variety of applications. This flexibility also has made standardization difficult, leading to problems comparing data from these different systems. In this work, we use the surface science techniques of X-ray photoelectron spectroscopy (XPS) and time-of-flight secondary ion mass spectrometry (TOF-SIMS) to analyze the components of DNA. The atomic ratios of the components of nucleobases, nucleosides, and nucleotides were characterized by XPS. The chemical shifts in the high-resolution XPS spectra allow for their relatively easy resolution. The unique positive and negative ions from the nucleobases, nucleosides, and nucleotides in their TOF-SIMS spectra were identified. This information was used to build a comprehensive table of all of the molecular ions. These standard spectra of DNA components can be used to predict the relative amounts of the bases within more complex molecules either by univariate analysis (i.e., by relating the base molecular ions to the sugar fragment ions within the nucleotides) or by multivariate analysis (e.g., principal component analysis). Our preliminary examination of four oligonucleotides shows promising results in that we can distinguish between two oligomers of similar composition using univariate and multivariate analysis, although additional studies are needed to expand this method to more complex oligomers.

Recurrent convulsions in a thoroughbred foal: management and treatment

A thoroughbred foal had a convulsive attack 12 hours after birth followed by further convulsions on the 10th, 11th and 12th days after birth. It was treated successfully by medication with primidone, feeding by stomach tube and careful nursing.

Acute and chronic venous insufficiency in the finger

Venous hypertension with subsequent chronic venous insufficiency and its sequelae in the hand is reported as an uncommon complication of arteriovenous fistulae for hemodialysis.

Anastomoses in the alimentary tract using a sero-muscular tubular cuff technic

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