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Background Multiple hereditary exostosis is a benign condition that can lead to significant forearm deformity secondary to physeal disturbances. As the child grows, the deformity can worsen as relative shortening of the ulna causes tethering, which may lead to increased radial articular angle, carpal slippage, and radial bowing, over time this tethering can also result in radial head subluxation or frank dislocation. Worsening of forearm deformities often require corrective reconstructive osteotomies to improve anatomic alignment and function. The purpose of this study is to evaluate the effectiveness of osteochondroma excision and distal ulnar tether release on clinical function, radiographic anatomic forearm alignment, and need for future corrective osteotomies. Methods The authors reviewed a retrospective cohort of preadolescent patients who underwent distal ulna osteochondroma resection and ulnar tethering release (triangular fibrocartilage complex). Patients were invited back and prospectively evaluated for postoperative range of motion, pain scores, self-reported and parent-reported Disabilities of the Arm, Shoulder, and Hand (DASH) and Pediatric Outcomes Data Collection Instrument (PODCI) scores. In addition, preoperative and final postsurgical follow-up forearm x-rays were reviewed. Results A total of 6 patients and 7 forearms were included in our study with an average age of 7.9 years at time of surgery. The average final follow-up was 7.4 years. With respect to range of motion, only passive radial deviation demonstrated improvement -20 to 14 degrees (P=0.01). Although there was not statistically significant change in radial articular angle, this study did find an improvement in carpal slip 75.7% to 53.8% (P=0.03). At final follow-up DASH score was 5.71 (σ=5.35), PODCI Global Function score was 95.2 (σ=5.81), and PODCI-Happiness score 98 (σ=2.74). Visual analogue scale appearance and visual analogue scale pain assessment were 1.67 (σ=1.21) and 1.00 (σ=1.26), respectively, at final follow-up. No patient in the cohort developed a radial head dislocation. Only one of 7 forearms required a corrective osteotomy within the study's follow-up time period. Conclusions Surgical excision of forearm osteochondromas with ulnar tether release in the preadolescent patients improves carpal slip, may help to prevent subsequent surgical reconstruction and provides satisfactory clinical results at an average 7-year follow-up. Level of evidence Level III-therapeutic study.

CASE A 9-year-old boy sustained a right distal clavicle physeal separation with superior and posterior displacement through the periosteum. He was treated surgically with open reduction, Kirschner wire fixation, and periosteal repair and had an excellent outcome. CONCLUSION Distal clavicle fractures are rare in children, and acromioclavicular joint (ACJ) separations are exceedingly rare. Differentiating between the 2 is often difficult radiographically and clinically. Our case represents a Type IV distal clavicle fracture but could be confused with an ACJ separation. Surgical treatment was successful.

Background: The purpose of this investigation was to determine the reliability of the Oberg-Manske-Tonkin (OMT) classification system applied to patients enrolled in a prospective, multicenter cohort study of congenital upper limb differences. Our hypothesis was that the OMT classification would exhibit high intraobserver and interobserver reliability and thus would be an appropriate tool for the new Congenital Upper Limb Differences registry. Methods: Four pediatric hand surgeons independently reviewed the medical records, clinical photographs, and radiographs of 60 randomly selected patients previously enrolled in the Congenital Upper Limb Differences registry. Patient’s information was summarized and shared electronically (PowerPoint). Each rater classified each congenital anomaly according to the OMT classification system. Responses were recorded using a web-based data capture tool (REDCap). Three weeks later, the surgeons repeated the process. Intraobserver reliability for each rater was assessed using Fleiss’ κ. Interobserver reliability was assessed using percent exact agreement (when all 4 raters were in agreement) as well as Fleiss’ κ. Results: Using the OMT classification, intraobserver reliability for the 4 pediatric hand surgeons showed almost perfect agreement, with κ values in the range of 0.89 to 0.93. Interobserver reliability demonstrated substantial agreement, with κ value of 0.79 (95% confidence interval, 0.77-0.82) in the first reading and 0.80 (95% confidence interval, 0.77-0.83) in the second reading. The highest possible agreement (κ=1) was seen for the following diagnoses: congenital dislocation of radial head (OMT I.A.2.v), Madelung deformity (I.A.2.vii), radial polydactyly (I.B.2.iii), triphalangeal thumb (I.B.2.iv), Kirner deformity (I.B.4.vi), and osteochondromatosis (3.B.4.i). Conclusions: The OMT classification of congenital upper limb differences exhibits substantial to almost perfect intraobserver and interobserver reliability among pediatric hand surgeons at different institutions. The OMT is therefore well-suited for classification of congenital upper limb anomalies in patients enrolled in a multicenter registry. Level of Evidence: Level II—diagnostic.

Background: The physical risk factors leading to distal radial fractures are poorly understood. The goal of this study was to compare postural stability between older adults with and without a prior distal radial fragility fracture. Methods: This case-control evaluation was performed at a single tertiary institution. The fracture cohort comprised 23 patients treated for a low-energy distal radial fracture within 6 to 24 months prior to this study. Twenty-three age and sex-matched control participants, without a prior fragility fracture, were selected from an outpatient clinic population. All participants completed a balance assessment with a computerized balance platform device. Dynamic motion analysis (DMA) scores ranging from 0 to 1,440 points are produced, with lower scores indicating better postural stability. Participants also completed validated questionnaires for general health quality (EuroQol-5D-3L [EQ-5D-3L]) and physical activity (Physical Activity Scale for the Elderly [PASE]) and comprehensive health and demographic information including treatment for compromised balance or osteoporosis. Statistical analysis compared data between cases and controls using either the Student t test or the Mann-Whitney U test. Results: There were no significant differences (p > 0.05) in age, sex, body mass index, physical activity score, or EQ-5D-3L general health visual analog scale score between participants with or without prior distal radial fracture. The fracture cohort demonstrated poorer balance, with higher DMA scores at 933 points compared with 790 points for the control cohort (p = 0.008). Nineteen patients (83%) in the fracture cohort reported having dual x-ray absorptiometry (DXA) scans within 5 years prior to this study, but only 2 patients (9%) had ever been referred for balance training with physical therapy. Conclusions: Older adults who sustain low-energy distal radial fractures demonstrate impaired postural stability compared with individuals of a similar age who have not sustained such fractures. Following a distal radial fracture, these patients may benefit from interventions to improve postural stability. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Even in metropolitan areas, on-call pediatric surgeons may not always be immediately available for surgical care of appendicitis, potentially leading to delays in care. In 2012, the in-house trauma group at a suburban Level 1 trauma center (none with formal pediatric fellowship training) assumed surgical care of 5-year- to 10-year-old children with appendicitis, who had previously been cared for by pediatric surgeons. We propose to compare the outcomes of the trauma and pediatric surgery groups. METHODS Retrospective chart review of 5-year- to 10-year-olds undergoing emergency appendectomy at a suburban Level 1 trauma center between January 2007 and December 2016 was performed. Patients were classified as having surgery performed by the trauma surgery group or the pediatric surgery group. Patient characteristics, clinical course, and outcomes were compared. RESULTS A total of 220 patients were identified for study, 138 in the trauma group and 82 in the pediatric surgery group. Patients cared for by the trauma group were more likely to be female (47% vs. 32%; p = 0.03), were less likely to be diagnosed without imaging (2% vs. 26%; p < 0.0001), had a shorter time from diagnosis to surgery (214 vs. 318 minutes; p = 0.01), were more likely to have laparoscopic surgery (70% vs. 55%; p = 0.04), had a shorter operative time (40 vs. 49 minutes; p < 0.0001), and had a shorter length of stay (32 vs. 41 hours; p < 0.0001), despite more of them needing to be transferred from outside hospitals (60% vs. 37%; p < 0.001). There were no significant differences in patient age, rate of perforated appendicitis, 30-day readmissions, surgical site infections, or unanticipated procedures. CONCLUSIONS Trauma surgeon performance of emergency appendectomy in 5-year- to 10-year-old children decreased length of hospitalization with similar complication rates as compared with pediatric surgeons. LEVEL OF EVIDENCE Therapeutic study, level IV.

To report the incidence of neonatal brachial plexus palsy with and without ipsilateral clavicle fracture in a population of newborns and to compare the prognosis between these subgroups.This was a retrospective review of 3,739 clavicle fractures and 1,291 brachial plexus palsies in neonates over a 24-year period from a geographically defined health care system with reference to county-wide population data.A referral clinic for children with brachial plexus palsies evaluated 1,383 neonates, of whom 320 also had ipsilateral clavicular fracture. As a result of referral patterns within the region, it is likely that this represents nearly all infants from the area with persistent brachial plexus injury after 2 months of age. Among the children evaluated without concomitant clavicular fracture, 72% resolved spontaneously (154/214); among those with concomitant clavicular fracture, 74% healed spontaneously (55/74). Limiting the analysis to neonates delivered at Parkland Memorial Hospital and assuming that those neonates with a discharge diagnosis of brachial plexus injury with or without clavicular fracture who did not present to the referral brachial plexus injury clinic had complete resolution, 94.4% without clavicular fracture resolved and 98.1% with clavicular fracture resolved (P=.005).The risk of persistent neurologic deficit from a birth-related brachial plexus palsy is lower than what has been reported, and the presence of a clavicle fracture may improve the likelihood of recovery.III.

Background: Despite advances in microsurgery, digit replantation now is performed less frequently in the U.S. compared with fifteen years ago. There has been uncertainty regarding whether previously reported U.S. replantation success rates and results reported from other countries reflect the current experience in the U.S. We hypothesized that the success of digit replantation at two academic level-I referral hospitals in the U.S. would be similar to previously published results. Methods: In this retrospective case series, we examined all cases of digit replantation that were performed from 1997 through 2010 at two institutions. The cumulative rate of viable digit replantations was determined. Binary logistic regression modeling determined the relative impact of patient, injury, and operative factors on replantation survival. Results: During the study period, 135 digit replantations were performed in 106 patients. Fourteen cases did not meet our inclusion criteria, yielding a cohort of 121 replantations. The thumb (n = 40) was the most commonly replanted digit, followed by the long finger (n = 31). The mechanism of injury was classified as sharp in eighty-three digits, crush in nineteen digits, and avulsion in eighteen digits. The majority of replantations were performed following Tamai level-III (n = 49) or level-IV (n = 56) amputations. Sixty-nine (57%) of the digit replantation procedures were successful. Logistic regression analysis identified replantation of the radial three digits and no history of tobacco use as significant independent predictors of replantation success. Conclusions: The rate of success of digit replantation (57%) at two academic level-I trauma hospitals was lower than previously published rates. Radial-digit involvement and no prior tobacco use were associated with replantation success. This modest success rate reflects a need for additional evaluation of our current benchmarks and clinical settings for replantation surgery. These data help to better inform patients, families, and physicians who are considering digit replantation. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

SUMMARY Radial longitudinal deficiency is a spectrum of upper extremity dysplasia and hypoplasia affecting the proximal arm and the radial aspect of the forearm, wrist, and hand. Often, the hand surgeon is the first to evaluate a patient with radial longitudinal deficiency and thus must be aware of its common associated syndromes. Specific evaluation, including clinical examination and laboratory testing, is necessary. At this time, there are many surgical approaches that can be used for treatment of radial longitudinal deficiency. The procedures should be specifically tailored to the patient and family to improve overall function and clinical outcome.

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.

Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively.A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test.All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors.Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.

Background: Necrotizing fasciitis (NF) has been associated with certain "hard" clinical signs (hypotension, crepitance, skin necrosis, bullae, and gas on x-ray), but these may not always be present. Using results of a previous study, we developed a simple model to serve as an adjunctive tool in diagnosing NF (admission WBC > 15.4 × 10 9 /L or serum sodium [Na] Study Design: A retrospective review was conducted of consecutive NF (n = 31) and non-NF patients (n = 328) treated at a single institution during an 11-month period. Comparison of admission vital signs, physical examination findings, radiology results, and number of patients meeting model criteria was performed. Results: Ninety percent of NF patients and 24% of non-NF patients met model criteria (p Conclusions: Admission WBC greater than 15.4 × 10 9 /L and serum Na less than 135 mmol/L are useful parameters that may help to distinguish NF from non-NF infection, particularly when classic "hard" signs of NF are absent.

Sometimes give of your services for nothing. And if the opportunity for serving a stranger in financial straits, give full assistance to all such. For wherever the art of medicine is loved, there is also a love of humanity—Hippocrates As the quotation above suggests, the selfless giving of one’s services and time has been recommended by generations of medical leaders since medicine’s earliest emergence as a paid profession. Whether such recommendations are prescriptive (i.e., what a physician should do if he or she is so inclined) or descriptive (i.e., what a physician is obligated to do, given his or her skills, as part of being a physician) has long been a subject of debate. The philosophical center of the debate is whether health care is a “right”—regardless of one’s ability to pay for it or deliver himself or herself to a physician. For if it is indeed a “right,” we are obligated to provide care to all. One man’s right is another man’s moral and ethical obligation. In this spirit, a recent American Orthopaedic Association (AOA) symposium and round table discussion (at the 2012 annual meeting) explored whether volunteerism should be considered a “core competency” and, if so, how we might implement it as we do the other competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). It is our opinion that a careful reading of the currently accepted ACGME competencies indicates that volunteerism clearly falls under the “professionalism” umbrella and should be considered part of what we must do (and must teach) to be (and to produce) complete, competent orthopaedic surgeons. In an on-site survey, the audience felt strongly that role modeling by faculty is an important predictor of resident behavior. Although most of the audience felt neutral about incorporating an international elective in a resident curriculum, …