Monteggia fracture‑dislocations in children: a structured approach to management.

Missed Monteggia injuries

Traumatic radiocapitellar dislocations that remain unreduced for more than 4 weeks are usually irreducible by closed means and are considered chronic Monteggia injuries (Fig. 14.1) [1]. The term “Monteggia fracture-dislocation” refers to all fractures of the ulna, irrespective of their location, that are associated with dislocation of the radial head. Monteggia fracture-dislocations are uncommon injuries that only account for about 1% of all pediatric forearm fractures [2, 3]. Despite its overall rarity, this injury is one of the most frequently missed injuries in children. Misdiagnosis is because the radial head dislocation is often overlooked and associated with plastic deformation of the ulna [1, 4]. An estimated 33% of acute Monteggia injuries are missed, making it the most common cause of chronic radial head subluxation [1, 5]. Another source of chronic injury is the loss of reduction following closed treatment, which can be seen in up to 20% of cases, especially when the ulnar fracture is oblique [1, 5–7].

Lisfranc injuries are traumatic disruptions of the tarsometatarsal joint complex. Injuries range from subtle ligamentous injuries to significant fracture dislocations. These relatively uncommon injuries are frequently missed during the initial presentation in emergency departments. Delayed or inadequate treatment can lead to chronic pain, midfoot arthritis, and significant functional disability. Early recognition and appropriate management of Lisfranc injuries are crucial for achieving optimal outcomes. Treatment strategies range from conservative management for stable injuries to surgical intervention for displaced or unstable injuries.

Background Ulnar carpometacarpal (CMC) joint dislocations and fracture-dislocations are uncommon injuries that are often overlooked. Most authors advocate surgical stabilization in order to prevent a secondary dislocation assuming that these injuries are inherently unstable. Case Description This is a series of eight ulnar CMC joint dislocations and fracture-dislocations treated by closed reduction and splint immobilization after assessing the joint stability. Mean follow-up was 30.2 months, and minimum follow-up was 12 months. Satisfactory results were obtained in range of motion, grip strength, pain, DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire, and time to return to working activities. In the same period, the closed reduction and cast failed two (20%) cases that were referred for surgery. Literature Review There is little published literature on the nonoperative treatment of these injuries. Most of them are isolated case reports, whereas the largest series reports four cases. All of them have reported satisfactory results. Clinical Relevance Based on our results, we believe that if the diagnosis of an ulnar CMC joint dislocation or fracture-dislocation is early accomplished and a concentric and stable reduction is initially achieved, the nonoperative treatment may be a successful option to take into account but requiring a close follow-up for the first week.

Perilunate dislocations and fracture dislocations represent uncommon and unusual injuries that are often missed at initial presentation and diagnosed late in up to 25% of cases. Prompt open reduction, carpal stabilisation and ligamentous repair is required to reduce the risk of complications. We report a case of an established scaphoid non-union in an operatively managed perilunate fracture dislocation that spontaneously united almost 2 years after the initial injury, just before a planned revision scaphoid fixation with bone grafting. This case highlights the importance of initial clinical assessment together with appropriate radiographs and follow-up of these injuries post-operatively, especially when complications such as non-union arise.

ObjectivesThe aim of this study was to estimate the patterns of care and annual levels of healthcare resource use attributable to managing pressure ulcers (PUs) in clinical practice in the...

Monteggia variant with posterior elbow dislocation and radial shaft fracture: A case report

Adenovirus pneumonia is common in pediatric upper respiratory tract infection, which is comparatively easy to develop into severe cases and has a high mortality rate with many influential sequelae. As for pathogenesis, adenoviruses can directly damage target cells and activate the immune response to varying degrees. Early clinical recognition depends on patients’ symptoms and laboratory tests, including those under 2 years old, dyspnea with systemic toxic symptoms, atelectasis or emphysema in CT image, decreased leukocytes, and significantly increased C-reaction protein (CRP) and procalcitonin (PCT), indicating the possibility of severe cases. Until now, there is no specific drug for adenovirus pneumonia, so in clinical practice, current treatment comprises antiviral drugs, respiratory support and bronchoscopy, immunomodulatory therapy, and blood purification. Additionally, post-infectious bronchiolitis obliterans (PIBO), hemophagocytic syndrome, and death should be carefully noted. Independent risk factors associated with the development of PIBO are invasive mechanical ventilation, intravenous steroid use, duration of fever, and male gender. Meanwhile, hypoxemia, hypercapnia, invasive mechanical ventilation, and low serum albumin levels are related to death. Among these, viral load and serological identification are not only “gold standard” for adenovirus pneumonia, but are also related to the severity and prognosis. Here, we discuss the progress of pathogenesis, early recognition, therapy, and risk factors for poor outcomes regarding severe pediatric adenovirus pneumonia.

The treatment of acute pediatric Monteggia injuries involving a complete fracture of the ulna remains controversial. The purpose of this study is to compare the outcomes of immediate operative fixation to a trial of closed reduction and casting of acute pediatric Monteggia fractures involving complete ulna fractures. We performed a retrospective analysis of 73 patients with Monteggia injuries with complete ulna fractures presenting to 2 pediatric trauma centers from 2008 to 2018. Patients were divided in 2 groups based on the treatment received: patients in group 1 (n=37, 51%) received surgical treatment; patients in group 2 (n=36, 49%) received a trial of closed reduction and casting. The mean follow-up of 15.2 weeks (range, 4.1 to 159 wk). The incidence of radiocapitellar joint redislocation, need for further intervention, complications, and recovery of range of motion was compared between the groups. There were no significant differences between groups 1 and 2 with regards to age (6 vs. 5.8 y, P=0.69), sex (54% vs. 47% female, P=0.64), or the mean maximal ulnar angulation (23 vs. 19 degrees, P=0.94). There was a higher proportion of proximal ulna fractures in group 1 versus 2 (62% vs. 33%, respectively, P=0.02). Bado type III and IV fractures were associated with operative management [odds ratio=22 (95% confidence interval: 1.68-288.7) and 14.9 (95% confidence interval: 2.09-106), respectively]. In group 2, 5 patients (13.9%) sustained a loss of radiocapitellar joint reduction following closed reduction and casting and ultimately received operative treatment. At final follow-up, there were no cases of recurrent radiocapitellar dislocation in either group, all patients achieved fracture union and regained full elbow range of motion. Even in the presence of a complete ulna fracture, a trial of nonoperative management of acute pediatric Monteggia fractures with closed reduction and casting can result in comparable outcomes to those obtained with immediate surgical management. The nonoperative management of Monteggia fractures requires close clinical follow-up to ensure no loss of reduction. Level IV-therapeutic studies, case series.

Predicting the final clinical phenotype after the first attack of optic neuritis

Objective Factitious disorders are known to exist in the medical community but are not commonly diagnosed in clinical practice. The majority of the literature on factitious disorder comes from case reports or case series. This particular case is unusual because it describes a patient who initially presented with purely physical complaints, but over time, the symptoms transitioned into predominantly psychiatric concerns. This case describes the patient's unique presentation and is followed by a discussion of the management of factitious disorder. Methods The patient was seen during the course of an inpatient psychiatric hospitalization. Electronic chart review was conducted, and information from each prior hospitalization was gathered between the dates of first initial documented presentation available in the electronic record in 1995 to most recent hospitalization in 2017. Results The patient still continues to present to the emergency department. Upon each presentation, staff work to objectively assess his complaints to be sure that there is no true underlying medical emergency. There is also a focus on providing non-judgmental, supportive, and compassionate care. Conclusion This case highlights the importance of corroborating objective findings with the patient's subjective reports gathered during a history and physical, and to recognize that patients with this disorder can present to any specialty. Thus, the collaboration between specialties is critical in the care of these patients to minimize unnecessary, costly, and sometimes dangerous interventions.

Functional Neurological Disorders (FND) are common in clinical practice. It is recognized that FND may present at onset or during the course of other neurological diseases (functional comorbidity). We report a clinical series of three patients who initially presented positive signs of a functional movement disorder (FMD) and were later diagnosed with a Creutzfeldt-Jakob disease (CJD). All patients presented with unilateral functional tremor, two patients also had functional limb weakness. All patients progressed to an asymmetric corticobasal syndrome, fulfilling clinical criteria of CJD. They had a rapid progression and died within 2-3months. FND may be the initial clinical presentation of neurodegenerative diseases reflecting a dysfunction across brain circuits that are involved in the pathophysiology of FND. A positive diagnosis of FND is essential as it is an adequate examination and a close follow-up of these patients in neurology clinics.

A RARE CASE OF LEMIERRE'S SYNDROME CAUSED BY PREVOTELLA BUCCAE

Summary Early recognition of schizophrenia and bipolar disorder has been a popular and important research topic in the last years. Even though the early symptoms of these disorders may emerge in adolescence, the disorders themselves usually remain un- or misdiagnosed for up to several years. Research has shown that this delay in treatment or a wrong treatment all together may have a negative impact on the course of a disorder. Therefore, several early recognition programs aim at identifying individuals at risk for schizophrenia and bipolar disorder before the disorders beome fully manifest. The early recognition programs are mostly based on assessment of various constellations of psychopathological symptoms. However, many of these symptoms, as well as other risk factors, are simultaneously predictive for many psychiatric disorders, making the early recognition processes difficult. Therefore, objectively measureable biological markers indicating the presence, absence or stage of a disorder are being searched for. Despite the intense research, no biomarker with sufficient sensitivity and specificity has been found until now. The aim of this dissertation was to investigate the frontal brain functioning in the individuals at risk for schizophrenia and bipolar disorder and through that contribute to the early recognition research. The data used in this dissertation were gathered within the framework of the Zurich Program for Sustainable Development of Mental Health Services (Zurcher Impulsprogramm zur nachhaltigen Entwicklung der Psychiatrie, ZInEP), subprojects 2 and 6. Subproject 2 (Early Recognition) aimed to identify individuals at risk for schizophrenia and bipolar disorder. Additionally to psychopathology assessment, neuropsychological testing has been conducted to find cognitive dysfunctions in the at-risk individuals. Subproject 6 aimed to identify neurophysiological abnormalities, which can be used as potential biomarkers for the at-risk state of schizophrenia and bipolar disorder. The studies presented in this work used the functional near-infrared spectroscopy (fNIRS) to measure the brain activation during two neuropsychological tasks. This method is particularly fitting for the early recognition research because it is relatively insensitive to movement and it is well suited for restless participants who may have problems during long monotonous i studies. Furthermore, it is inexpensive and easy to apply, which could facilitate investigating large study populations as well as transition to the clinical practice in the future. The prefrontal cortex (PFC) has been chosen as the region of interest in both studies presented here. Previous research has reported cognitive deficits as well as related deficits in PFC functioning in manifest schizophrenia and bipolar patients. Study 1 assessed emotional interference measured by the emotional Stroop task, whereas Study 2 used a well-established semantic…

To explore the number of patients presenting with sepsis before and after guideline implementation; the impact of sepsis guidelines on triage assessment, emergency department management and time to antibiotics. Sepsis remains one of the leading causes of mortality and morbidity within hospitals. Globally, strategies have been implemented to reduce morbidity and mortality rates, which rely on the early recognition and management of sepsis. To improve patient outcomes, the New South Wales government in Australia introduced sepsis guidelines into emergency departments. However, the impact of the guidelines on clinical practice remains unclear. A 12-month pre-post retrospective randomised medical record audit of adult patients with a sepsis diagnosis. Data were extracted from the emergency department database and paper medical record. Data included patient demographic (age, gender), clinical information (time of arrival, triage code, seen by time, disposition, time to antibiotic, pathology, time to intravenous fluids) and patient assessment data (heart rate, respiratory rate, blood pressure, temperature, oxygen saturations, medication). This study demonstrated a statistically significant 230-minute reduction in time to antibiotics post implementation of the guidelines. The post group (n=165) received more urgent triage categories (n=81; 49·1%), a 758-minute reduction in mean time to second litre of intravenous fluids and an improvement in collection of lactate (n=112, 67·9%), also statistically significant. The findings highlight the impact the guidelines can have on clinician decision-making and behaviour that support best practice and positive patient outcomes. The sepsis guidelines improved the early assessment, recognition and management of patients presenting with sepsis in one tertiary referral emergency department. The use of evidenced-based guidelines can impact clinical decision-making and behaviour, resulting in the translation and support of best practice and improving patient care.