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Background Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. Methods This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications. Results The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. Conclusions With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. Level of evidence Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

The current literature suggests that the majority of patients with a low-velocity gunshot wound can be treated nonoperatively with local wound care and antibiotic prophylaxis. Surgical removal of the bullet is not typically recommended for nonarticular fragments1,2, as the long-term consequences of a retained bullet are thought to be insignificant. However, increased lead levels in any patient and particularly in a fetus or growing child can result in permanent disability3-6. We describe the case of an adolescent girl who sustained a gunshot wound to the foot resulting in an elevated blood lead concentration to a dangerous and teratogenic level. Both the patient and her mother were informed that data concerning the case would be submitted for publication. A fourteen-year-old girl sustained a gunshot wound to the back of the ankle when walking up the stairs in front of her house as she was returning from school. The bullet entered the posterolateral aspect of the heel. Radiographs revealed fractures of the talus and lateral malleolus, as well as a bullet embedded in the talar neck and multiple shards of metal along the bullet track (Fig. 1). The results of neurovascular examination were normal. In the emergency room, antibiotics and tetanus prophylaxis were administered. She was taken to the operating room emergently for irrigation and debridement of local soft tissue as well as the ankle and subtalar joints. The bullet had passed between the fibula and tibia, removing bone from each, and from the posterior aspect of the talar body into the talar neck, where it had created a comminuted fracture. Because of softtissue swelling and concerns for the vascular supply to the talus, no attempt was made initially to access the talus or bullet from an anterior approach, and the bullet could not …

The differentiation between septic arthritis and transient synovitis of the hip in children can be difficult. The purpose of the present study was to validate a previously published clinical prediction rule for this differentiation in a new patient population.We prospectively studied children who presented to a major children's hospital between 1997 and 2002 with an acutely irritable hip. As in the previous study, diagnoses of septic arthritis (fifty-one patients) and transient synovitis (103 patients) were operationally defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression were used to compare the two groups. The predicted probability of septic arthritis of the hip from the prediction rule was compared with actual distributions in the current patient population. The area under the receiver operating characteristic curve was determined.The same four independent predictors of septic arthritis of the hip (a history of fever, non-weight-bearing, an erythrocyte sedimentation rate of 40 mm/hr, and a serum white blood-cell count of12,000 cells/mm(3) (12.0 x 10(9)/L)) were identified in the current patient population. The predicted probability of septic arthritis of the hip from the prediction rule was similar to the actual distributions in the current patient population. The area under the receiver operating characteristic curve for the current patient population was 0.86, compared with 0.96 in the original population.Clinical prediction rules typically demonstrate diminished performance in a new patient population because they are optimally modeled to the original data set. The previously published clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children demonstrated diminished, but nevertheless very good, diagnostic performance in a new patient population.

The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.

Background: Legg-Perthes disease is associated with ischemia of the capital femoral epiphysis in children. Thrombophilia has been implicated as a potential cause of the condition, and screening of patients with Legg-Perthes disease for thrombophilia has been recommended. We analyzed the value of screening for inherited thrombophilia in patients with Legg-Perthes disease by examining the association between Legg-Perthes disease and abnormalities in the thrombotic pathway. Methods: A random series of consecutive patients with Legg-Perthes disease were prospectively enrolled in this study. Assays for the detection of factor-V Leiden mutation and the plasma concentrations of protein C, protein S, antithrombin III, and lipoprotein (a) were performed on plasma samples from children with Legg-Perthes disease, and the results were compared with those for pooled plasma from normal controls. Plasma concentrations below the 95% midrange of the control values were classified as protein deficiencies. The estimated population frequency of each coagulation abnormality was compared with the proportion of the study group with the corresponding abnormality. Results: The proportion of abnormalities observed in the study group did not differ from the estimated population frequency for protein C, protein S, antithrombin III, or factor-V Leiden mutation. A lipoprotein (a) level of >30 mg/dL (>1.07 μmol/L) was found in 16% of the study group. Conclusions: Our data do not suggest that thrombotic diatheses due to deficiency of protein C, protein S, or antithrombin III or due to factor-V Leiden mutation are major causes of Legg-Perthes disease. The elevated levels of lipoprotein (a) in children with Legg-Perthes disease suggest that they may be at risk for atherosclerosis as adults.

A prospective study was done of the results of infusion of drained blood after major procedures on the spine and hip in twenty-six patients. The Solcotrans system was used to salvage drained blood in the first six hours after the operation. Transfusion requirements, blood loss, hematocrit, temperature, prothrombin time, partial prothrombin time, platelet count, results of blood cultures, and levels of factor VIII, factor V,D-dimer, antithrombin III, plasminogen, protein C, and complement C3a des arginine were determined for some or all of the patients. A mean of 375 milliliters of blood from the Solcotrans receptacle was reinfused. All of the cultures were negative. There were no febrile reactions. The mean values for the specimens of the salvaged blood were: hematocrit, 0.20; hemoglobin, seventy-one grams per liter; plasma hemoglobin, 2.36 grams per liter; C3a des arginine, 9.4 x 10(-3) grams per liter; fat particles of less than nine micrometers in diameter, 23,643 per milliliter; and D-dimer, 205 x 10(-3) grams per liter. Studies of blood samples that were collected from patients one to two hours and twelve to eighteen hours after the transfusion showed only slight increases in fibrin split products one hour after the transfusion; these values reverted to normal by eighteen hours. No clinical coagulopathy associated with reinfusion was observed. The reinfusion of unwashed, filtered shed blood that was as much as 15 per cent of the total blood volume proved to be a safe technique after major orthopaedic procedures.