Journal of pediatric orthopedics
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Forty-seven children with 32 open tibial fractures, 11 open femoral fractures, and six closed tibial fractures with compartment syndrome, which were surgically opened, were assessed for the time to union and incidence of nonunion and infection. Treatment varied with fracture severity and patient age. Tibial external fixators were supplemented by short-leg casts, and fixators were removed at an average of 7 weeks. ⋯ No pin-tract infections occurred in tibial fractures treated with external fixation with casting. The relation between age and time to union was statistically significant. In open fractures without segmental bone loss or soft-tissue loss requiring major reconstruction, bony healing can be expected within 6 months.
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Case Reports
Orthopaedic manifestations of invasive group A streptococcal infections complicating primary varicella.
The incidence of invasive group A streptococcal (GAS) infections in primary varicella appears to be increasing. GAS infections complicating varicella range from cellulitis, abscess, and septic arthritis to life-threatening necrotizing fasciitis and pyomyositis in association with GAS toxic shock syndrome (TSS). Four patients admitted in 1 year to the Children's Hospital and Medical Center in Seattle, whose care included evaluation and treatment by the Orthopaedic service, are presented to illustrate this spectrum. ⋯ These patients required aggressive fluid resuscitation and prolonged intensive care unit support. Diagnostic imaging studies were obtained in one patient with necrotizing pyomyositis but may have served only to delay definitive treatment. Recognition of the potential for secondary GAS infections and a high index of suspicion for the presence of necrotizing soft-tissue infection are essential in the evaluation of any child with fever and localized extremity pain with varicella.
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Thoracic outlet syndrome, although uncommon in children, may be precipitated during rapid growth in adolescence, especially in association with a cervical rib. Four children exhibited the aching, tiredness in the limb, and occasional paresthesia in adolescence. Two had a cervical rib requiring removal, after which the symptoms disappeared. ⋯ It is proposed that in a child, the anatomy of the thoracic outlet is constantly changing with growth and development of the structures that form the thoracic outlet, as well as those that traverse the outlet itself. A conservative approach to these symptoms is warranted in the first instance to allow further growth and remodeling of the thoracic outlet, which may be sufficient to accommodate the nerve roots and brachial plexus and alleviate the symptoms. Excision of the cervical rib in the presence of increasing and chronic symptoms can be quit beneficial.
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Epidural analgesia and anesthesia are standard regional techniques in orthopaedic surgery of the lower extremities. Benefits of epidural anesthetic infusions include excellent analgesia, minimal respiratory depression, no somnolence, and decreased need for blood transfusion. Adverse effects include pruritus, nausea, and urinary retention, but standard methods have evolved to counter each adverse effect. ⋯ Sixty-four patients experienced satisfactory analgesia with minimal adverse effects. The technique worked despite multiple laminotomies for segmental fixation and did not compromise neurologic assessment. We conclude that epidural analgesia is as safe and effective after spinal-deformity surgery as it is after other types of surgery.
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Randomized Controlled Trial Comparative Study Clinical Trial
Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation.
A prospective, randomized study of intravenous (i.v.) regional anesthesia compared with nitrous oxide gas was performed in a group of 28 pediatric patients with forearm fractures requiring manipulation in the emergency department. The groups were compared in terms of pain perceived by the patients, success of manipulation, safety, and duration of procedure. ⋯ Because of a technical problem with an i.v. regional block, fracture manipulation was not completed in one patient. Nitrous oxide treatment required significantly less time for completion of the procedure.