Supracondylar Humerus Fractures- Does remodeling of the bone affect the clinical outcome? What is the bearing of fracture geometry and type of fixation on remodeling?

Adequacy of treatment, bone remodeling, and clinical outcome in pediatric supracondylar humeral fractures.

J Pediatr Orthop B. 2011 Sep 22. [Epub ahead of print]

Persiani P, Domenica MD, Gurzi M, Martini L, Lanzone R, Villani C.

Source: Department of Orthopedics, Policlinico Umberto I, Roma, RM, Italy.

Abstract

Background: Completely displaced Gartland type III fractures should be addressed surgically, whereas Gartland type I fractures should be treated by casting alone. The best way to approach type II remains controversial, as it could be the first or second synthesis method, depending on fracture fragment stability after closed reduction.   We focused our study on two main aspects that influence the final outcome; the adequacy of treatment in relation to the Gartland types of fracture and the physeal remodeling

Material and Methods: The aim of this study was to evaluate and compare, both clinically and roentgenographically, 62 extension-type supracondylar fractures on the basis of the synthesis method and severity of the fracture, with a mean follow-up of 4 years and 3 months. Range of motion, axial alignment of the elbow, muscle strength, and joint stability were estimated and the Mayo Elbow Performance Index and the Pediatric Orthopaedic Society of North America Pediatric Outcomes Data Collection Instrument questionnaire were used. Furthermore, we took radiographic measurements (Baumann's angle, humero-capitellar angle, and lateral rotational percentage).

Results: According to Flynn criteria, the clinical outcome of all our patients was satisfactory. According to the results of the questionnaires, no patient has reported any disabling limitation of the elbow function. Radiographic study proved a greater capacity of remodeling in the sagittal plane compared with the frontal one, irrespective of severity of fracture assessed by the Gartland classification. Statistical analysis stressed the validity of postoperative Baumann's angle as a predictor of final carrying angle. With regard to the synthesis method, the best way to approach Gartland II fractures proved to be by closed reduction and percutaneous pinning; the use of a third Kirschner wire in the treatment of Gartland III fractures did not lead to a better result.

Conclusion: To conclude, remodeling positively influenced the clinical outcome, however, irrespective of synthesis method and severity of the fracture, we should pay more attention to the adequacy of reduction in frontal plane than in the sagittal one, for which a greater capacity of remodeling was proved.

Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors.

J Pediatr Orthop B. 2011 Jan;20(1):1-7.
Azzopardi T, Van Essen P, Cundy PJ, Tucker G, Chan A.


Source

Royal Hospital for Sick Children, Glasgow, UK. thomasazzopardi@hotmail.com

Abstract

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

IORG Paediatric orthopaedic update

Effect of pressure applied during casting on temperatures beneath casts.

J Pediatr Orthop. 2011 Oct-Nov;31(7):791-7.
Deignan BJ, Iaquinto JM, Eskildsen SM, Woodcock CA, Owen JR, Wayne JS, Kuester VG.

Abstract

BACKGROUND:

Burns and pressure sores are common injuries during cast application. Various factors such as water temperature, padding, and cast material layers may play a role in these injuries; however, the effect of cast molding on temperatures and pressures has not been investigated. This raises the following questions, does the application of molding during cast application: (1) alter skin level temperatures in a variety of cast materials? and (2) risk inducing either thermal injury or pressure necrosis?

METHODS:

An upper extremity model was created to measure pressure and temperature underneath casting materials. Cast padding, water bath temperature, and cast thickness were standardized. A 3-point mold was simulated using 3 casting materials-Fiberglass only, Plaster Only splint, and Plaster splint overwrapped with Fiberglass-while pressure and temperature were recorded.

RESULTS:

: Pressure application led to a statistically significant (P<0.0001) increase in temperature at the sites where the mold was applied although absolute temperature did not reach the theoretical burn threshold of 49 to 50°C for the casting materials studied. With pressure applied, the Plaster/Fiberglass combination reached an average peak temperature of 47.9°C, which was maintained for up to 6 minutes. Neither Fiberglass nor Plaster Only reached peak temperatures of this magnitude (average of 42.7 and 43.6°C, respectively). Peak (369 mm Hg) and highest residual (21 mm Hg) pressures were below harmful levels.

CONCLUSIONS:

Pressure application during casting is a risk factor for burn injuries. Care should be taken when molding a plaster splint overwrapped in fiberglass by waiting until the plaster has fully cooled.

CLINICAL RELEVANCE:

Combined with other known risk factors, the pressure from molding a cast could increase the likelihood of causing cutaneous burns.

IORG Paediatric Orthopaedic Update

SEPTIC ARTHRITIS – EVIDENCE FOR SHORT TERM ANTIBIOTIC THERAPY

SEPTIC ARTHRITIS – EVIDENCE FOR SHORT TERM ANTIBIOTIC THERAPY

Successful treatment of Septic arthritis in childrens depends on early diagnosis and prompt treatment. The standard of care for acute septic arthritis and osteomyelitis is prompt surgical drainage of any collection [1–4] followed by a 6-week course of antibiotics [5,6]. A debate about the duration of antibiotics has been raised in last few years [7].

REVIEW
Kim and Alman [8] reviewed 20 consecutive patients with culture-proven acute septic arthritis of the hip who were treated with a shortened course of parenteral antibiotic therapy, followed by oral antibiotics based on the patient’s response. They concluded that such a treatment plan was associated with no recurrence and a good clinical outcome. Blockey and Watson [9] stated that intravenous antibiotics could be stopped after 10 days if the erythrocyte sedimentation rate was decreasing and in the absence of radiologic cortical bone erosion or new bone formation. Nelson et al. [10,11] showed that a short duration of parenteral therapy followed by oral therapy was not associated with recurrence of infection. Tetzlaff et al. [12,13] reported on 30 patients with acute hematogenous septic arthritis and osteomyelitis who were treated by surgery and oral chemotherapy. Oral therapy provided increased patient comfort and decreased the risk of nosocomial infection associated with prolonged intravenous therapy. They stated that this mode of treatment should be carried out only under carefully monitored conditions in the hospital to ensure compliance and adequacy of serum bactericidal activity.

SHORT TERM THERAPY
Short term intravenous antibiotic therapy followed sequentially by oral antibiotics has been studied by two prospective trials by Jaberi et al[14] and Jagodzinski et al [15]. Jaberi et al had 33 patients in there series which they randomized. The septic arthritis patients received 1 week of v antibiotics in one group and 2 weeks of IV antibiotics in second group. Both the groups were then followed up with 4 weeks of oral antibiotics. Overall, excellent or good results were found in both groups with respect to eradication of infection, radiological and functional scores. The average hospital cost for a patient in second group was twice that for a patient in first group.

Jagodzinski et al studied 70 children’s prospectively. Their hypothesis stated that the majority of children with acute septic arthritis and osteomyelitis could be treated with 3 days of intravenous antimicrobial therapy, after prompt surgical drainage, followed by 3 weeks of oral therapy. Results showed that 59% of patients can be successfully converted to oral therapy by day 3 and 86% can be converted by day 5. Only 14% of patients in our study required intravenous therapy for 6 days or more.


HOW TO IDENTIFY WHICH PATIENT WILL REQUIRE PROLONGED THERAPY
Thus short term therapy is been backed up with good evidence, however the question remains of how to identify patients who will need prolonged therapy. Both the above studies have provided with their own guidelines. Jaberi et al used a scoring system that was based on clinical, laboratory and radiological criteria’s

Any patient with scores less than 4 were switched from intravenous to oral antibiotics and vice versa

In study by Jagodzinski et al, after 3 full days of intravenous antibiotics the patients were assessed with regard to converting to oral therapy. An improvement in symptoms (pain, movement), normalization of temperature, and stabilizing CRP were defined as prerequisites for conversion. Persistent pain, fever, and rising inflammatory markers dictated that therapy should continue and that surgical exploration could be indicated.

CONCLUSION
Thus in conclusion it can be said that present evidence points towards short term therapy for septic arthritis guided by the patients response to be quite effective in treatment.

USEFUL TIP-

Kocher et al [16,17] predicted that 99.6% of children who were non-weight bearing with a fever (defined as temperature above 38.41C), ESR greater than 40 mm/h, and WCC greater than 12000/cmm would have septic arthritis of the hip as opposed to transient synovitis.


REFERENCES
1. Chen CE, Ko JY, Li CC, et al. Acute septic arthritis of the hip in children. Arch Orthop Trauma Surg. 2001;121:521–526.

2. Deshpande SS, Taral N, Modi N, et al. Changing epidemiology of neonatal septic arthritis. J Orthop Surg Hong Kong. 2004;12:10–13.

3. Drees M, Ross JJ. Septic arthritis: treat early to minimize morbidity. J Musculoskelet Med. 2005;22:161–166.

4. Shaw BA, Kasser JR. Acute septic arthritis in infancy and childhood. Clin Orthop and Rel Res. 1990;257:212–225.

5. Mades JT, Calhoun J. Osteomyelitis. In: Mandell GL, Bennet JE, Raphael D, eds. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone; 2000:1182–1196.

6. Osteomyelitis. Available at: http://www.emedicine.com/emerg/ topic349.htm. Accessed February 20, 2008.

7. Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440–445.

8. Kim HK, Alman B. A shortened course Of parenteral antibiotic therapy in the management of acute septic arthritis of the hip. J Pediatr Orthop 2000;20:44–7.

9. Blockey NJ, Watson JT. Acute osteomyelitis in children. J Bone Joint Surg [Br] 1970;52:77–87.

10. Nelson JD, Bucholz RW, Kusmiesz H, et al. Benefits and risks of sequential parenteral-oral cephalosporin therapy for suppurative bone and joint infections. J Pediatr Orthop 1982;2:255–62.

11. Nelson JD, Howard JB. Oral antibiotic therapy for skeletal infections of children. J Pediatr 1978;92:131–4.

12. Tetzlaff TR, Mc Cracken GH, Nelson JD. Oral antibiotic therapy for skeletal infections of children. J Pediatr 1978;92:485–90.

13. Tetzlaff TR, Howard JB. Antibiotic concentration in pus and bone of children with osteomyelitis. J Pediatr 1978;92:135–40.

14. Jaberi FM, Shahcheraghi GH, Ahadzadeh M. Short-term intravenous antibiotic treatment of acute hematogenous bone and joint infection in children: a prospective randomized trial. J Pediatr Orthop. 2002 May-Jun;22(3):317-20.

15. Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009 Jul-Aug;29(5):518-25.

16. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg [Am]. 1999;81:1662–1670.
17. Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg [Am]. 2004;86A:1629–1635.