Little, KJ; Trehan, S; Cornwall, R; Garrison, S; Dastillung, E; McFadden, L. Decreasing Unexpected Returns to Orthopedic Hand Clinic Improving Efficiency of Health Care Delivery.. Pediatric Quality and Safety. 2018; 3(5):e107-112.
The purpose of this quality improvement effort was to reduce the unexpected return to clinic (URTC) visits from 1.8 per 100 patient follow-up visits by 50%. Pareto charts determined the common causes of URTC visits were cast issues (50.5%), new symptom/complaints (29.5%) and persistent or worse symptoms (15.2%). Interventions targeting minimizing cast usage and improved patient education were studied using Plan-Do-Study-Act cycles. URTC visit rates decreased from 1.8 to 0.7 (⇓62%) per 100 follow-up visits, and also resulted in a savings of more than $420 per visit.
Mehlman, CT; Denning, JR; McCarthy, JJ; Fisher, ML. Infantile Supracondylar Humeral Fractures Patients Less Than Two Years of Age Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation. The Journal of Bone and Joint Surgery. 2019; 101(1):25-34.
The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures in patients less than two years of age. Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was lateral column only vs. medial and lateral column fixation. A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004).
Murphy, HA; Jain, VV; Parikh, SN; Wall, EJ; Cornwall, R; Mehlman, CT. Extensor Tendon Injury Associated With Dorsal Entry Flexible Nailing of Radial Shaft Fractures in Children A Report of 5 New Cases and Review of the Literature.. Journal of Pediatric Orthopaedics. 2019; 39(4):163-168.
This is a literature review of 28 cases, and examination of 5 new cases, of extensor pollicis longus (EPL) tendon injury following the dorsal approach to elastic stable intramedullary nailing (ESIN) of the radius. EPL tendon injury was found to be a complication unique to the dorsal entry approach for ESIN of the radius, with 21/24 patients requiring further surgical intervention (treatment was unreported in 7 cases). The lateral approach appears to offer a safer alternative with regard to the EPL tendon and we recommend that physicians consider the risk of EPL tendon injury when planning for ESIN of the radius, and make an effort to avoid direct injury when using a dorsal approach.
Parikh, SN; Rajdev, N; Sun, Q. The Growth of Trochlear Dysplasia During Adolescence. Journal of Pediatric Orthopaedics. 2018; 38(6):e318-e324.
The purpose of this study was to assess the growth pattern of trochlear dysplasia in adolescents as assessed using the Dejour classification. Utilizing magnetic resonance images, results indicated that all linear measurements of trochlear dysplasia (condylar height, trochlear height, trochlear bump) increased with age. However, the shape of trochlear dysplasia, as reflected by sulcus angle and Dejour classification, did not change with increasing age. The shape of trochlear dysplasia is most likely a genetic predisposition and does not necessarily change during skeletal growth.
Denning, JR; Little, KJ. Standardization of Care of Common Pediatric Fractures. Orthopedic Clinics of North America. 2018; 49(4):477-490.
Distal radius fractures are the most common site of fracture in the pediatric population. Supracondylar humerus fractures are the most common pediatric elbow fracture. There is need for standardization of these types of injuries to optimize the quality, safety, and value for patients. Using quality improvement methodology to implement an evidence-based protocol for surgical treatment of supracondylar humerus fractures, compliance among the 13 surgeons at the author’s institution increased from 0% to 85% over 2 months and was maintained for over 14 months. As a result, the authors also decreased the number of surgeon preference cards for this procedure from 13 to 1 and reduced variability in supply and surgical charges and charge per patient. In regards to patients with distal radius buckle fractures, the percentage treated with braces was increased from 34.8% to 84% over a 6 month intervention period.