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Late presentation of supracondylar fracture of the humerus in children.

In children with delayed presentation of displaced supracondylar fractures, closed or open reduction with K-wire fixation risks complications. Gradually reducing the fracture with traction potentially reduces these risks. An unacceptable deformity can be corrected later by an osteotomy. This concept was used for 28 children, with an average age of 7 years 6 months, who presented after an average delay of 5.6 days. Their stay in the hospital was 14 days on average. At followup (average, 24 months), five children (18%) who had cubitus varus greater than 10 degrees had corrective osteotomy. There were no additional neurovascular injuries after treatment. The results are comparable with other methods of treatment.

Child↗

Anterior subcutaneous transfer of the ulnar nerve in the athlete.

To evaluate the effectiveness of subcutaneous subfascial anterior transfer of the ulnar nerve in the surgical treatment of cubital tunnel syndrome in athletes, we retrospectively reviewed athletes undergoing subcutaneous anterior transfer of the ulnar nerve at the elbow. Criteria for inclusion in the study included active participation in athletic activity, confirmed cubital tunnel syndrome, failure to respond to conservative treatment, and having an anterior subcutaneous subfascial transfer as the only procedure performed. Twenty athletes underwent a total of 21 procedures. Results were evaluated by time to return to sport and a questionnaire developed to evaluate elbow function in the athlete. The athletes returned to full activity at an average of 12.6 weeks. Average subjective postoperative scores were 84. Elbow rating scores averaged 9 (range, 0 to 10). Anterior subcutaneous subfascial transfer of the ulnar nerve is a safe, effective means for treating cubital tunnel syndrome in athletes. The findings in this study are significant in that they confirm the effectiveness of the subcutaneous subfascial transfer procedure in returning the athlete to competition. Of secondary importance is the development of an elbow rating questionnaire appropriate to the athlete.

Adolescent↗

Displaced supracondylar fractures of the humerus in children. Audit changes practice.

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assessed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries.

Bone Wires↗

The surgical management of pediatric fractures of the upper extremity.

The vast majority of pediatric fractures of the upper extremity can and should be treated with closed reduction, immobilization, and close follow-up. However, there is an ongoing debate in the orthopaedic community regarding the exact role of surgical management in the treatment of pediatric fractures. In the past 2 decades, surgical management of certain fractures (e.g., percutaneous pinning of displaced supracondylar fractures) has provided better results than closed management. Surgical management is clearly indicated for certain injuries, such as those requiring anatomic realignment of the physis or articular surface. Increasingly, however, surgical management is being used to maintain optimal alignment or to allow early motion. In many such cases, both nonsurgical and surgical methods have yielded good results and have vocal advocates. Certain technical advances, such as flexible intramedullary fixation and bioreabsorbable implants, have further increased enthusiasm for surgical management of pediatric fractures.

Adolescent↗

Orthopedic pitfalls in emergency medicine.

Acute orthopedic problems make up a large part of everyday emergency department practice. Misdiagnosis of these injuries often results from failure to consider certain clinical entities as a cause of the patient's complaints, and may result in unnecessary complications for the patient. Indeed, missed orthopedic injuries are the leading cause of malpractice claims in emergency medicine. The orthopedic injuries that most notoriously escape detection by the primary care physician are closed tendon injuries of the hand, carpal bone injuries, occult fractures about the elbow, femoral neck fractures, posterior dislocation of the shoulder, epiphyseal plate injuries, fractures of the pubic ramus, patellar tendon rupture, Lisfranc injuries, compartment syndromes, and multiple injuries. If the physician is unaware of these entities when evaluating the patient, he will not make the diagnosis. This review is designed to heighten the primary care physician's awareness of these injuries, which are a common source of problems in the emergency department.

Aged↗

[Treatment and outcome of supracondylar humeral fractures in childhood].

In an 8-year period, from 1985 to 1992, 89 children presenting with a supracondylar humeral fracture were treated at the Department for Traumatology, Philipps-University, Marburg. All dislocated fractures (n = 48) were treated surgically. The majority (n = 34) of dislocated fractures were reduced open by a radial and an ulnar approach and subsequently stabilized using crosswise introduced K-wires. All fractures were differentiated retrospectively according to the degree of dislocation, the presence of associated injuries, the type of treatment chosen, and the function outcome. Fifty-two patients were reexamined. Clinically relevant varus deformities (4% of cases) and impaired elbow function were observed only in cases where anatomic fracture reduction or fracture fixation was not obtained. Critical analysis of our results and the literature led us to the development of a new, treatment-oriented classification of supracondylar humeral fractures in children. We consider fractures that are dislocated less than 20 degrees, and where dislocation exists only in a saggital plane to be type A fractures. These fractures can be treated conservatively. Type B fractures are fractures that are dislocated more than 20 degrees only in the saggital plane, but with remaining ventral or dorsal cortical bony contact between the fragments. In these fractures, we perform closed fracture reduction and K-wire stabilization. Type C fractures are fractures with rotational deformity, fractures dislocated in a frontal plane and fractures dislocated in a saggital plane with loss of cortical bony contact between proximal and distal fragments. Type C fractures should be reduced open by both a radial and an ulnar approach and subsequently stabilized using K-wires, introduced crosswise.

Adolescent↗

The pediatric T-supracondylar fracture.

T-supracondylar fractures of the humerus occur rarely in children compared with the adult variety. Sixteen such fractures treated at the Children's Hospital of Eastern Ontario between 1975 and 1983 are described. There were nine male and seven female patients, 7-17 years old. All fractures were displaced, two were open, and one patient had an associated radial nerve palsy. All cases were managed by open reduction, internal fixation, and early mobilization. Follow-up revealed no cases of functional disability despite significant loss of motion in two patients. The conservative approach should be abandoned in these intraarticular injuries, and good operative results can be anticipated.

Adolescent↗

[Fibrinogen glue in osteochondral fractures with small fragments of the upper limb].

Fibrin sealant presents a satisfactory possibility for reconstruction of the joint surface, especially in cases of little osteochondral fragments. Our experience in 16 patients is detailed. The patients average age was 23 years. 34 osteochondral fragments had been glued in these 16 cases, 10 times at the finger joints, 4 times at the caput radii and 2 times at the trochlea humeri. The patients, who had been operated on from June 1979 to December 1984 have been followed up at an average of 2,1 years after the fibrin gluing. This method can avoid an early arthrodesis or oversized osteosynthetic material.

Adolescent↗

Risk of hip fracture after osteoporosis fractures. 451 women with fracture of lumbar spine, olecranon, knee or ankle.

In a follow-up study during 1976-1984, the risk of a subsequent hip fracture was investigated in women aged 60-99 years, hospitalized for the following fractures: lumbar spine (n 70), olecranon (n 52), knee (n 129) and ankle (n 200). Follow-up ranged from 0 to 9 years. Observation time of the 4 different fractures were 241, 180, 469, and 779, person-years, respectively. In women aged 60-79 years with one of the following fractures the relative risk of a subsequent hip fracture was increased by 4.8 (lumbar spine), 4.1 (olecranon), 3.5 (knee) and 1.5 (ankle). The relative risk of hip fracture showed a tendency to level off 3 years after the primary fracture.

Aged↗

[Mefenamic acid (Ponstan)-induced acute interstitial nephritis with reversible, severe, non-oliguric renal failure].

Acute interstitial nephritis is a rare complication of treatment with non-steroidal antiinflammatory drugs. A case is reported with severe, reversible, non-oliguric renal failure caused by biopsy-proven acute interstitial nephritis after therapy with mefenamic acid (Ponstan). Prednisone treatment resulted in normalization of renal function within 4 weeks.

Acute Kidney Injury↗