Background: Ectopic parathyroid tissue can pose difficulties in diagnosis, management, and resection of adenomas in patients with hyperparathyroidism. The use of multimodal pre-operative imaging is recommended due to the diverse anatomic presentation of parathyroid adenomas and the potential presence of multiple adenomas. Resection failure still can occur, however, indocyanine green (ICG) fluorescence imaging is an intraoperative tool that has potential to help address this challenge. In the case which follows we demonstrate the use of ICG fluorescence imaging to assist in successful resection of a parathyroid adenoma located within the carotid sheath.Case Description: We present the case of a 75-year-old woman with primary hyperparathyroidism due to a parathyroid adenoma localized to the left carotid sheath, posterior to the carotid artery. Careful resection was aided by ICG fluorescence guidance allowing for complete resection and immediate postoperative restoration of normal Parathyroid Hormone and calcium levels. The patient had no peri-operative complications and had an unremarkable post-operative course. Conclusions:The anatomical heterogeneity of parathyroid gland adenomas within and around the carotid sheath presents a unique diagnostic and surgical scenario; however, the use of intra-operative ICG, as presented in this case, has important implications for endocrine surgeons and surgical trainees alike. This tool provides improved intra-operative identification of the parathyroid tissue allowing for safe resection, especially in cases involving critical anatomical structures.

The ideal technique to measure medial epicondyle humerus fracture displacement minimizes radiation exposure while maximizing measurement accuracy and reliability. This study compares the radiation exposure and accuracy of displacement measurements of the four-view X-ray examination (XR), computed tomography (CT) and in-clinic cone-beam CT (CBCT). A cadaveric humerus underwent medial epicondyle osteotomy. The fragment was fixed to the humerus at clinically relevant displacements (6 to 18 mm). Dosimeters were placed around the distal humerus and simulating thyroid location. XR, CT and CBCT were performed at each displacement. Four pediatric orthopedists measured the maximum linear displacement on each XR and 3D reconstruction of the CT and CBCT images. Focal (elbow location) and thyroid radiation exposure was compared between modalities. Intra- and interclass correlation coefficients (ICC) for displacement measurements were determined. Mean focal radiation exposures for XR, CT and CBCT were 0.008, 2.061 and 0.478 rad, respectively (P = 0.001). Exposures 10 inches from the elbow for XR, CT and CBCT were 0.001, 0.066 and 0.010 rad, respectively (P = 0.006). At 12 inches, there was no significant difference in exposure between XR and CBCT (P = 0.114). Intra- and interobserver reliabilities were excellent for all measures, except lateral x-ray. CBCT and CT had significantly less deviation from the actual displacement compared to XR (P < 0.05). In-office CBCT of the elbow exposes patients to significantly less radiation than conventional CT. All X-ray images (except lateral), CT and CBCT had equal reliability in evaluating medial epicondyle fractures, which contrasts with previous evidence.

Background: Opioid abuse and overdose are in epidemic range in the United States and medical prescriptions, including those for postoperative analgesia, are a large contributing source to this misuse. Our quality improvement initiative aimed to reduce the opioid prescribing of pediatric orthopaedic surgeons in the postoperative setting. The aim was to decrease the percentage of children with surgically treated supracondylar humerus (SCH) fractures who are prescribed opioid medications at discharge from a baseline of 40% to 10% within 6 months. Setting/Local Problem: The study took place at an urban level 1 trauma center at a children’s hospital. The orthopaedic team completed closed reduction and percutaneous pinning for SCH fractures over a 14-month baseline period. Forty percent of these patients were discharged with an opioid prescription. After assessing baseline prescription rates, a multidisciplinary team of health professionals developed a key driver diagram. Interventions: Primary interventions included orthopedic department-wide pain management education, reporting of prescription rates during monthly conferences, and provider-specific feedback. The primary measure was the percentage of patients prescribed opioids upon discharge following closed reduction and percutaneous pinning of Type II and III SCH fractures. As a balancing measure, we tracked the use of a 24-hour nurse triage line for pain-related follow-up in the intervention period. We used statistical process control to examine changes in measures over time. Results: The percentage of patients receiving opioid prescriptions upon discharge following surgically treated SCH fractures decreased from 40% to 8% over 5 months and sustained for an additional 16 months. Conclusions: Through provider education, feedback, and regular reporting, we decreased the number of pediatric patients with surgically treated SCH fractures that were discharged with any opioid prescription by 80% over 5 months while ensuring clinically adequate pain control.

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