Level IV-therapeutic.

Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

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Background: While reconstruction of the medial patellofemoral ligament (MPFL) is one of the most frequently performed surgical procedures in skeletally immature patients with patellar instability, there is an inherent risk to the distal femoral physis during femoral tunnel placement Methods: This case report describes a distal femoral valgus deformity caused by partial lateral physeal growth arrest after MPFL reconstruction.   Results: The acquired distal femoral valgus deformity was successfully treated with a distal femoral varus-producing osteotomy.  Conclusion: This case highlights the importance of understanding the distal femoral anatomy and avoiding areas where the physis may be violated.

Background: Closed reduction is generally attempted on children under 18 months of age who present as older infants or who fail nonoperative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will ultimately require open reduction (OR). Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. Methods: Prospectively collected data from 4 select centers of an international multicenter study group sharing a common treatment approach were reviewed for all DDH infants under 18 months old that required operative management. Patients were categorized into 2 groups: those whose hips were successfully closed reduced or those who ultimately required OR. Factors were compared between the closed reduction and OR groups for 2 separate cohorts—those presenting early in life with ultrasound (US) data, and those presenting later with radiographic data. Results: A total of 154 patients (166 hips) were included in the analysis. Overall, 87.3% were female. In the early-presenting cohort, purposeful entry multivariate regression revealed that patients with Graf IV hips on US had 3.8 times higher odds of requiring an OR. For the later cohort, hips that were clinically irreducible (ie, negative Ortolani sign) had 3.3 times higher odds of requiring OR. Patients with International Hip Dysplasia Institute (IHDI) grade IV hips had 2.5 times higher odds of needing an OR versus those with grade III hips and 15.4 times higher odds than those with grade II hips. Children with an IHDI grade IV hip and a negative Ortolani sign had 4.4 times higher odds of needing OR. Conclusion: Children younger than 18 months with dislocated hips who require OR are more likely to have a high-grade radiographic dislocation (IHDI grade IV), negative preoperative Ortolani sign, and a Graf IV classification on initial US. This information may help surgeons budget the use of operating room time and better counsel parents about intraoperative expectations. Level of Evidence: Level III—Prognostic.

Background: Traditional management of hand abscesses consists of withholding antibiotics prior to drainage to optimize bacterial culture growth and outcome. The purpose of this study was to determine the effect of preoperative empiric antibiotics on the rate of culture growth and rate of adverse events in patients with acute hand abscesses. Methods: We performed a retrospective review of prospectively collected data on 88 consecutive hand abscesses that received empiric antibiotics prior to incision and drainage from 2012 to 2013 at an urban academic institution. We analyzed patient demographics, bacteriology, culture growth results, time to surgery, and frequency of adverse events. Results: The overall rate of positive culture growth was 90% (n = 79) despite running the antibiotics for a mean of 31 hours prior to debridement. Furthermore, 96% of the isolates were given a susceptible antibiotic during that time. The mean number of debridements was 1.5 per patient, but 4 re-operations were necessary for wound complications. No patients required an amputation or were upgraded to intensive care. Conclusions: Preoperative empiric antibiotic administration does not appear to greatly reduce bacterial culture growth from hand abscesses. The adverse events are relatively few for simple abscesses treated with pre-surgical antibiotics and decompression within 24 hours.