Tibial shaft fractures are a commonly seen injury in orthopedic trauma patients. Fractures commonly occur following high energy mechanisms, such as motor vehicle collisions. There are multiple ways to stabilize tibial shaft fractures. Knowledge of the indications, contraindications, techniques, and complications associated with each technique allows the orthopedic surgeon to make the appropriate decision for each patient by providing both fracture and patient characteristics. This review discusses the indications, techniques, outcomes, and complications associated with intramedullary nailing, minimally invasive percutaneous plate osteosynthesis, and external fixation of tibial shaft fractures.

The treatment of scoliosis has been explored and debated in medicine since the first recorded texts. Scoliosis treatment has shifted over time from external modalities, such as traction and bracing, to internal stabilization techniques that leverage surgical advances. Surgical fixation constructs can generally be separated into two different modalities: dynamic vs. static constructs. For skeletally immature individuals with progressive deformities, surgical options range from traditional or magnetically controlled growing rods to vertebral body staples or tethering. For individuals who have reached skeletal maturity, many devices have been developed that provide static length constructs. Understanding the surgical options available is critical for the appropriate management of this varied patient population. With this article, we sought to provide a summary of past and present techniques and devices used in the treatment of scoliosis.

Objective: Wide awake local anesthesia no tourniquet (WALANT) techniques are increasingly utilized for hand surgeries in adults, given the clinical benefits to patients, reduced environmental waste during surgery, and lower costs to the health care system. This technique is not widely employed for pediatric hand surgeries given concerns for parental and patient anxiety, noncompliance during surgery, and tolerance of administration of local anesthesia. Select patients undergoing amenable procedures can potentially benefit from this method and enjoy the lower morbidities and costs that adult patients enjoy. It was hypothesized that WALANT technique would be safe, efficient, and feasible in a pediatric cohort. Methods: A retrospective chart review of all 223 upper extremity surgeries performed by a single surgeon at a pediatric hospital and its surgery center was performed. Patients aged 7 to 20 years scheduled for local anesthesia without monitored anesthesia care were included. These patients were not instructed to fast before their procedure. Patient demographics, surgical and recovery room times, pain scores, and complications were recorded. Results: Eighty-six patients underwent surgery under local anesthesia and were compared with 76 patients undergoing similar surgeries under general anesthesia. Both soft tissue and bony surgeries were included. The WALANT group had both significantly shorter average length of surgery and time spent in recovery compared with the general anesthesia group, translating into significant cost savings. Lower pain scores and fewer narcotic prescriptions were noted. There were no conversions to any type of monitored anesthesia care, nor cancellations due to inability to tolerate administration of local. No difference in infection rates or other complications were noted between groups. Conclusions: WALANT is safe, efficient, and feasible in a pediatric hospital for a variety of surgeries. Expanding this technique for use in select children allows patients, their families, and the health care system to enjoy the clinical, financial, and environmental benefits of WALANT surgery. Level of Evidence: Level III—retrospective comparative study.

Background: With an annual incidence of 177 per 100,000 patients, supracondylar humerus fractures (SCHF) are the most common elbow fracture in the pediatric population. ^1,2 Pain control after closed reduction and percutaneous pinning (CRPP) of SCHF may be improved with the use of a local anesthetic. We aimed to assess the effects of local bupivacaine administration on immediate post-operative pain and opioid requirements. Methods: A retrospective chart review was performed for patients undergoing CRPP of SCHF from September 1, 2018 to September 30, 2022 at a single institution. Two groups (local vs. no local) were formed based on intraoperative administration of bupivacaine. Post-anesthesia care unit (PACU) records were reviewed for type and dose of pain medications administered and pain scores. Results: Three hundred thirty-five patients (114 local, 221 no local) were included in review. No differences were noted in demographic or injury characteristics. The local and no-local groups had average PACU pain scores of 2.2±3.2 and 3.3±3.5, respectively. There was no significant difference between groups in percentage of patients who received Tylenol, Motrin, and Toradol. There was a significant difference in the number of patients who received morphine with 42% of patients in the local group requiring morphine compared with 64% of patients in the no-local group. The average weight-based dose of morphine in the local group was 0.002 mg/kg±0.001 and 0.003 mg/kg±0.008 in the no-local group. No differences were noted in postoperative complications or unexpected follow-up. Conclusions: The use of local bupivacaine intraoperatively improved pain control as evidenced by fewer patients requiring morphine and lower pain scores in the local group. Local bupivacaine is a low-cost, low-risk intervention that can be used after CRPP of SCHF that may improve immediate postoperative pain and facilitate quicker transition to oral pain medications with decreased need for IV opioid medications. Level of Evidence: Level IIIB—retrospective comparative study.