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Background. Because they are associated with a high energy mechanism, open distal femoral physeal fractures are rare injuries. Appropriate management of these injuries is critical in the pediatric population due to the increased risk of damage to the physis and subsequent growth disturbance and deformity after injury. Pediatric fractures may also represent the sequelae of genetic syndromes (particularly connective tissue disorders), nutritional abnormalities, or conditions that predispose to abnormal bone mineral density. Clinical case. In this case report, we present the case of a 9-year-old girl with tetrasomy 18p who presented with a grossly displaced right open distal femoral physeal fracture in the setting of isolated, lower extremity trauma. The patient underwent an irrigation and debridement, followed by an open reduction and cross-pinning through the distal femoral epiphysis. After the operation, the patient was made non-weight-bearing in a cast for 4 weeks, and at 6 weeks, the pins were removed. The patient had full range of motion at the 6-month follow-up and then resumed her preinjury level of play at school. Discussion. Tetrasomy 18p results in inherent muscle weakness that may interfere in the normal soft tissue sleeve of muscles stabilizing long bones. This may result in greater displacement of fractures sustained during trauma, which may lead to a greater rate of vascular injury, physeal injury, and poor overall prognosis. It is imperative for clinicians to be familiar with tetrasomy 18p and its associated orthopedic manifestations. Conclusion. There is scarce literature on the management of physeal fractures in patients with tetrasomy 18p. In the case described here, we report a good outcome with the standard of care using preoperative and postoperative antibiotics, irrigation and debridement, open fracture fixation, and immobilization in a cast postoperatively. The duration of non-weight-bearing was also increased by 1 week and the pins were removed 1 week later than we would have for patients without any bone or connective tissue disorders.

Propionibacterium acnes should be considered in any case of indolent septic arthritis. Cultures should be followed for 2 weeks as our cultures were negative for 7 days before growing P. acnes. Irrigation and debridement followed by antibiotics is the standard of care.

Introduction Vertebral osteomyelitis (VO) is an uncommon infection with Staphylococcus aureus as the most commonly implicated organism. VO caused by nontuberculous mycobacteria (NTM) such as Mycobacteriumabscessus (M. abscesscus) is exceedingly rare with only eight cases reported in literature. Case presentation We report a rare case of an 82-year-old male with a remote history of trauma who was diagnosed with NTM vertebral osteomyelitis. The patient initially underwent a vertebroplasty of T12 and kyphoplasty of L1 for pathologic compression fractures. Subsequent cultures revealed M. abscessus. The patient further underwent an anterior T12-L2 corpectomy and debridement with instrumented fusion, as well as a posterior T9-L4 instrumentation and fusion. He received multi-agent antibiotic therapy; however, was ultimately unable to tolerate the aggressive treatment regimen and his prolonged postoperative course. Discussion Nontuberculous mycobacteria vertebral osteomyelitis is exceedingly rare. NTM vertebral osteomyelitis is challenging to treat. Surgical management plays a limited role in early VO, but is the mainstay treatment in chronic VO. Early recognition of the condition and shared patient management with multidisciplinary teams is key to successfully treating cases of NTM VO.

Nontraumatic spinal subdural hematomas secondary to anticoagulants are remarkably rare. A case of spontaneous, atraumatic subdural hematoma involving the thoracic region in an 80-year-old woman on warfarin is reported. The patient presented with gross motor and sensory loss, delayed onset of incontinence, and no other symptoms. An MRI suggested an epidural hematoma concentrated around the T4-T9 levels. She was taken emergently to the OR approximately 30 hours after the initial onset of symptoms for a T3-T11 laminectomy. No epidural hematoma was noted. However, discoloration and bulging of the thecal sac were noted, and the dura was incised longitudinally from T2 to T10 revealing an expansive jelly-like blood clot which was evacuated. Postoperatively, the patient had regained 1/2 sensory function in the bilateral lower extremities. At the 2-week mark, the patient was still incontinent and showed 2/2 sensory and 2/5 motor functions in select muscle groups in her bilateral lower extremities. Completely nontraumatic, spontaneous subdural hematomas of the spine are very rare, and early surgical decompression within 24 hours from symptom onset may allow neurological recovery. Large extensive laminectomies up to 10 thoracic levels have been shown to be safe and effective in a few cases, including our case.

Background: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. Methods: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients’ demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. Results: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes ( P = .03) or underlying psychiatric disorders ( P = .03). Conclusion: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. Level of Evidence: Level III, comparative series.