Showing papers in "Journal of Pediatric Orthopaedics in 2014"

Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent Athletes

Abstract: Background:Much attention has been given to the relationship between various training factors and athletic injuries, but no study has examined the impact of sleep deprivation on injury rates in young athletes. Information about sleep practices was gathered as part of a study designed to correlate va

A classification of growth friendly spine implants.

Abstract: Background Various types of spinal implants have been used with the objective of minimizing spinal deformities while maximizing the spine and thoracic growth in a growing child with a spinal deformity. Purpose The aim of this study was to describe a classification system of growth friendly spinal implants to allow researchers and clinicians to have a common language and facilitate comparative studies. Growth friendly spinal implant systems fall into 3 categories based upon the forces of correction the implants exert on the spine, which are as follows: Distraction-based systems correct spinal deformities by mechanically applying a distractive force across a deformed segment with anchors at the top and bottom of the implants, which commonly attach to the spine, rib, and/or the pelvis. The present examples of distraction-based implants are spine-based or rib-based growing rods, vertical expandable titanium rib prosthesis, and remotely expandable devices. Compression-based systems correct spinal deformities with a compressive force applied to the convexity of the curve causing convex growth inhibition. This compressive force may be generated both mechanically at the time of implantation, as well as over time resulting from longitudinal growth of vertebral endplates hindered by the spinal implants. Examples of compression-based systems are vertebral staples and tethers. Guided growth systems correct spinal deformity by anchoring multiple vertebrae (usually including the apical vertebrae) to rods with mechanical forces including translation at the time of the initial implant. The majority of the anchors are not rigidly attached to the rods, thus permitting longitudinal growth over time as the anchors slide over the rods. Examples of guided growth systems include the Luque trolley and Shilla. Conclusions Each system has its benefits and shortcomings. Knowledge of the fundamental principles upon which these systems are based may aid the clinician to choose an appropriate treatment for patients. Having a common language for these systems may aid in comparative research. Vertical expandable titanium rib prosthesis is used with humanitarian exemption. The other devices mentioned in this manuscript are not approved for growing constructs by the Food and Drug Administration and are used off-label.

The shilla growth guidance technique for early-onset spinal deformities at 2-year follow-up: A preliminary report

Abstract: Background:The Shilla growth guidance technique has been developed to treat spinal deformities without the necessity of repeated operative lengthenings. The dual stainless steel rods are fixed to the corrected apex of the curve by pedicle screws with limited fusion about the apex. Vertebral growth o

Fibro-adipose vascular anomaly: clinical-radiologic-pathologic features of a newly delineated disorder of the extremity.

Abstract: Ahmad I. Alomari, MD, MSc, FSIR,*wSamantha A. Spencer, MD,wzRyan W. Arnold, MD,*wGulraiz Chaudry, MBChB,*wJames R. Kasser, MD,wzPatricia E. Burrows, MD,yPradeep Govender, MD,*wHoracio M. Padua, MD,*wBrian Dillon, MD,*wJoseph Upton, MD,w8Amir H. Taghinia, MD,w8Steven J. Fishman, MD,wzJohn B. Mulliken, MD,w8Rebecca D. Fevurly, MD,wzArin K. Greene, MD,w8Mary Landrigan-Ossar, MD, PhD,w#Harriet J. Paltiel, MD,w** Cameron C. Trenor, III, MD,wwwand Harry P. Kozakewich, MDwzz

Complications after modified Dunn osteotomy for the treatment of adolescent slipped capital femoral epiphysis

Abstract: Background: Modified Dunn osteotomy has gained popularity over the past decade in the treatment of moderate to severe adolescent slipped capital femoral epiphysis. The purpose of this study was to retrospectively evaluate a consecutive series of adolescent slipped capital femoral epiphysis patients treated with the modified Dunn procedure at a single institution. We analyze the indications for the procedure as well as the complications after surgical treatment. Methods: Forty-three adolescent patients (18 boys and 25 girls) were treated with the modified Dunn procedure at our institution between September 2001 and August 2012. The average follow-up for this cohort was 2.6 years (range, 1 to 8 y). Complications were graded according to the modified Dindo-Clavien classification. Results: Twenty-six patients (60%) had an unstable injury with an inability to ambulate with our without crutches. Seventeen patients (40%) had an acute injury with duration of symptoms 50 degrees. Twenty-two complications occurred in 16 patients (37%) in this cohort. Fifteen revision procedures were performed for femoral head avascular necrosis, fixation failure with deformity progression, or postoperative hip dislocation. Two patients developed end-stage degenerative joint disease and severe femoral head avascular necrosis and were referred for a total hip arthroplasty. Conclusions: The complication rate in this series is higher than most previous reports. This may be in part because of the fact that as a tertiary referral center our patient population was more complex. However, we identified a clear inverse relationship between surgeon-volume and patient-outcomes. On the basis of our results we have modified our practice. A high-volume surgeon must be present during each modified Dunn procedure, and only patients that have sustained an acute severe (>50 degrees) epiphyseal displacement with mild chronic remodeling of the metaphysis that can be addressed within 24 hours of the slip may be treated with the modified Dunn technique. Level of Evidence: Level IV—therapeutic study.

Arthroscopic versus conservative treatment of first anterior dislocation of the shoulder in adolescents.

Abstract: Background:Conservative treatment of posttraumatic antero-inferior shoulder instability leads to a high failure rate in a young and active population. However, treatment in an adolescent age group is not well documented.Methods:We conducted a prospective study with adolescent patients (age 15 to 18

Correction of lower extremity angular deformities in skeletal dysplasia with hemiepiphysiodesis: a preliminary report.

Abstract: BACKGROUND Lower extremity angular deformities are common in children with skeletal dysplasia and can be treated with various surgical options. Both acute correction by osteotomy with internal fixation and gradual correction by external fixation have been used with acceptable results. Recently, the Guided Growth concept using temporary hemiepiphysiodesis for correction of angular deformities in the growing child has been proposed. This study presents the results of temporary hemiepiphysiodesis using eight-Plates and medial malleolus transphyseal screws in children with skeletal dysplasia with lower extremity angular deformities. METHODS Twenty-nine patients (50 lower extremities) with skeletal dysplasia of different types were treated for varus or valgus deformities at 2 centers. The mean age at the time of hemiepiphysiodesis was 10±2.9 years. A total of 66 eight-Plates and 12 medial malleolus screws were used. The average follow-up time between the index surgery and the latest follow-up with the eight-Plate in was 25±13.4 months. Erect long-standing anteroposterior and lateral view radiographs were obtained for deformity planning before the procedure. Angular deformities on radiograph were evaluated by mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and lateral distal tibial angle. Mechanical axis deviation was also expressed as a percentage to one half of the width of the tibial plateau, and the magnitude of the deformity was classified by determining the zones through which the mechanical axis of the lower extremity passed. Four zones were determined on both the medial and lateral side of the knee and the zones were labeled 1, 2, 3, and 4, corresponding to the severity of the deformity. A positive value was assigned for valgus alignment and a negative for varus alignment. RESULTS Patients were analyzed in valgus and varus groups. There was correction in 34 of 38 valgus legs and 7 of 12 varus legs. In the valgus group, the mean preoperative and postoperative mechanical lateral distal femoral angles were 82.1±3.7 and 91.1±4.9 degrees, respectively (P<0.001). The mean preoperative and postoperative medial proximal tibial angles were 98.5±8 and 87.8±7.1 degrees, respectively (P<0.001). Six patients with bilateral ankle valgus deformities (12 ankles) underwent single-screw medial malleolus hemiepiphysiodesis. The mean preoperative and postoperative lateral distal tibial angles were 73.9±8.7 and 86.1±6.8 degrees, respectively (P<0.001). The numbers of plates in each anatomic location were not enough to make statistical conclusions in varus legs. Four patients in the valgus group and 3 patients in the varus group did not benefit from the procedure. Mechanical axes were in zone 2 or over in 94% of the legs preoperatively, whereas postoperatively, only 23% of the legs had mechanical axes in zone 2 or over in varus and valgus groups. CONCLUSIONS Growth modulation with an eight-Plate is a relatively simple surgery and has low risk of mechanical failure or physeal damage. It can be performed in very young patients, which is an important advantage in skeletal dysplasia. Screw purchase is reliable even in the abnormal epiphysis and metaphysis. Our results show that Guided Growth using eight-Plates in skeletal dysplasia is safe and effective. LEVEL OF EVIDENCE Level IV.

The role of capital realignment versus in situ stabilization for the treatment of slipped capital femoral epiphysis.

Abstract: Introduction:Slipped capital femoral epiphysis (SCFE) can be treated by a variety of methods with the traditional method of in situ pin fixation being most commonly used. More recently, the Modified Dunn (Mod. Dunn) procedure consisting of capital realignment has been popularized as a treatment meth

Treatment trends in adolescent clavicle fractures.

Abstract: BACKGROUND: Controversy continues with regard to decision making for operative treatment of adolescent clavicle fractures, while the literature continues to support operative treatment for select middle third fractures in adults. The purpose of our study was to evaluate the recent trends in nonoperative and operative management of adolescent clavicle fractures in the United States. METHODS: Data were derived from a publicly available database of patients, PearlDiver Patient Records Database. The database was queried for ICD-9 810.02 (closed fracture of shaft of clavicle), with the age restriction of either 10 to 14 or 15 to 19 years old, along with CPT-23500 (closed treatment of clavicular fracture) and CPT-23515 (open treatment of clavicular fracture) from 2007 to 2011. The χ analysis was used to determine statistical significance with regard to procedural volumes, sex, and region. The Student t test was used to compare average charges between groups. RESULTS: A significant increase in the number of adolescent clavicle fractures managed operatively (CPT-23510, ages 10 to 19 y) from 309 in 2007 to 530 in 2011 was observed (P<0.0001). There was a significantly greater increase in operative management of clavicle fractures in the age 15 to 19 subgroup compared with the age 10 to 14 subgroup (P<0.0001). In the operative group, there was a trend toward a higher number of males being managed with operative intervention. The overall average monetary charge for both nonoperatively and operatively managed adolescent clavicle fractures increased significantly in the study period. A statistically significant increase in normalized incidence of operatively managed adolescent clavicle fractures was noted in the midwest, south, and west regions with the greatest increase in west region where the incidence increased over 2-fold (P<0.0001). CONCLUSIONS: Adolescent clavicle fractures seem to be being treated increasingly with open reduction and internal fixation recently, especially in the 15 to 19 age group. Nevertheless, there remains of lack of high-level studies comparing outcomes of operative and conservative treatment specifically for the adolescent population to justify this recent trend. LEVEL OF EVIDENCE: Level IV-retrospective database analysis.

Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years.

Abstract: Background:Fractures of the clavicle are common among adolescents and have traditionally been treated nonoperatively. Recent literature has demonstrated less satisfactory results than expected after conservative management of displaced fractures in adults. The purpose of this study was to evaluate t

Radial neck fractures in children: results when open reduction is indicated.

Abstract: Radial proximal metaepiphyseal fractures are uncommon and account for 5% to 10% of all elbow fractures in skeletally immature patients.1–6 The frequency of associated lesions is quite variable, 15% to 60% in reported series.2–5,7–9 The treatment of radial neck fractures in children varies according to the fracture’s displacement, angulation, and skeletal maturity. Most fractures are nondisplaced or minimally displaced and can be treated with closed reduction and casting with a good outcome.10,11 There is a general agreement that displaced radial neck fractures with >30-degree angulation should be surgically treated.9,11–13 Treatment options include percutaneous pin reduction,8,14,15 elastic stable intramedullary nailing,5,15–18 and open reduction with or without internal fixation.3,9,17,19 Open reduction is a method of treatment often used in comminuted fractures or in fractures with a completely displaced head anteriorly or posteriorly on the radial metaphysis and when closed reduction has failed. Reports in the literature note higher rates of complications after open compared with closed reduction.17,19–21 Most authors agree that worse results may follow open treatment but it is the more severe fractures that warrant a more aggressive approach. Whether poor results are a consequence of treatment or the magnitude of the bony and soft tissue injury is not clear. In series reported in the literature, when the head of the radius remains displaced >30% and angulated >45 degrees after attempts of closed or percutaneous reduction, an open reduction is indicated.2,5,19,20 The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated (>60 degrees) fracture who underwent open reduction when closed reduction failed. Results were reviewed at a significant follow-up time and factors leading to poor results were identified

Spine trauma in very young children: a retrospective study of 206 patients presenting to a level 1 pediatric trauma center

Abstract: BACKGROUND: The immature spine has anatomic and biomechanical properties that differ from the adult spine and result in unique characteristics of pediatric spinal trauma. Although distinct patterns of spinal injury have been identified in children younger than 10 years of age, little research has explored the differing characteristics of spinal trauma within this age group, particularly in the very young. The purpose of this study is to identify differences in the epidemiology and characteristics of spinal trauma between children under the age of 4 years and those between 4 and 9 years of age. METHODS: A review of all patients treated for spinal injury at a single large level I pediatric trauma center between 2003 and 2011 was conducted. Demographic data, injury mechanism, neurologic status, and details of any associated injuries were compiled. Radiographic studies were used to determine injury location and fracture classification. The patient population was divided into 2 groups: the infantile/toddler (IT) group (ages 0 to 3 y) and the young (Y) group (ages 4 to 9 y). Data were compared between these groups using the χ2 test and the Student t test to identify differences in injury characteristics. RESULTS: A total of 206 patients were identified. Fifty-seven patients were between 0 and 3 years of age and 149 were between 4 and 9 years old. Although motor vehicle collision was the most common cause of injury in both the groups, nonaccidental trauma was responsible for 19% of spine trauma among patients aged 0 to 3 years. Cervical spine injuries were much more common in the youngest patients (P<0.05) with injuries primarily in the upper cervical spine. Children in the IT group were more likely to sustain ligamentous injuries, whereas Y patients had more compression fractures (P<0.05). Neurologic injury was common in both the groups with IT patients more often presenting with complete loss of function or hemiplegia and Y patients sustaining more spinal cord injuries (P<0.05). IT patients had a 25% mortality rate, which was significantly higher than that of the Y group (P=0.005). CONCLUSIONS: This study shows many significant differences in characteristics of spinal injury in infants/toddlers when compared with older children. These differences can help guide diagnostic evaluation and initial management, as well as future prevention efforts. LEVEL OF EVIDENCE: Level III.

Clinical characteristics of severe supracondylar humerus fractures in children.

Abstract: Background:The safety of delayed surgical treatment of severe supracondylar elbow fractures in children remains debated No large studies have evaluated complications of injury and surgery evaluating only type 3 fractures Our aim was to review the results of our experience treating children with se

Psychosocial effects of repetitive surgeries in children with early-onset scoliosis: are we putting them at risk?

Abstract: Background The use of growing instrumentation in children with early-onset scoliosis (EOS) has created interest in determining if these repetitive procedures are prompting the development of lasting psychosocial problems Given the increasing role of this treatment modality in the management of EOS, this study aimed to assess the psychological status of this patient population and to determine factors associated with worse scores in various psychosocial domains Methods A cross-sectional assessment of 34 EOS patients was performed utilizing 2 well-established, caregiver-completed psychiatric instruments: the Child Behavior Checklist (CBCL) and the Strength and Difficulties Questionnaire Scores were calculated for 15 CBCL and 6 Strength and Difficulties Questionnaire domains and subdomains and grouped as "Normal" or "Abnormal" according to published normative values The prevalence of abnormal scores was within each instrument subdomain and was compared with the national norms Domain scores were also correlated with age at first scoliosis surgery, total number of operative procedures, and total number of growing instrumentation surgeries Results A higher prevalence of Abnormal scores were found in multiple psychosocial domains in our cohort as compared with national normative data Children with Abnormal CBCL "Total Problems" domain scores were younger at the time of first scoliosis surgery (250 vs 552 y) Normal and Abnormal scoring groups showed significant differences in the number of (1) total surgeries; (2) total scoliosis surgeries; and (3) growing instrumentation surgeries in multiple domains on both instruments Aggression, Rule-breaking, and Conduct were positively correlated with total number of surgeries Conclusions Our findings showed a higher prevalence of Abnormal psychosocial scores in multiple domains in multioperated EOS patients as compared with national norms Our findings suggest that EOS patients with abnormal psychosocial scores were younger at the time of their initial scoliosis surgery The number of repetitive surgeries also correlated positively with 3 behavioral problem scores Although healthier scores were seen in 1 positive behavioral domain in more operated children suggesting the potential for "posttraumatic growth," the other findings of this study are concerning given the increasing use of this treatment modality and indicate a need for ongoing screening and mental health care in this high-risk population Level of evidence Level III--case-control

Anterior Cruciate Ligament Reconstruction in Children With A Quadrupled Semitendinosus Graft: Preliminary Results With Minimum 2 Years of Follow-up

Abstract: Background: The management of anterior cruciate ligament (ACL) tears in growing patients must balance activity modification with the risk of secondary (meniscal and cartilaginous) lesions, and surgical intervention, which could adversely affect skeletal growth. Many ACL reconstruction techniques have been developed or modified to decrease the risk of growth disturbance. We have not found any description of ACL reconstruction using a single hamstring, short graft implanted into intraepiphyseal, retroreamed sockets. Our hypothesis was that the technique that we used restored the knee stability and did not cause any growth disturbances. Methods: We retrospectively studied 28 patients (20 boys, 8 girls) who presented with a unilateral ACL tear and open growth plates. We performed short graft ligament reconstruction with the semitendinosus folded into 4 strands around 2 polyethylene terephthalate tapes. The graft was implanted into sockets that were retroreamed in the femoral and tibial epiphysis and the tapes were fixed remotely by interference screws. After a minimum period of 2 years, we evaluated the comparative knee laxity, the radiographic limb morphology, the appearance of secondary lesions, and the functional outcomes using the Lysholm and Tegner scores. Comparative analyses were performed using the Student t test with subgroups depending on the type of fixation used. Results: The mean age of the patients was 13 years (range, 9 to 15 y). The mean follow-up was 2.8 years (range, 2 to 5 y). The mean difference in laxity at 134 N was 0.3 mm, as determined using a GNRB arthrometer. No patients reported meniscal symptoms or degenerative changes. We found no angular deformity or leg length inequality. Two patients suffered a recurrent ACL tear. Conclusions: The preliminary results from this series are consistent with prior studies demonstrating that intraepiphyseal ACL reconstruction is a safe reliable alternative for the pediatric population. Study Design: Case series; level of evidence 4.

Gait patterns in children with limb length discrepancy.

Abstract: BACKGROUND:: Very few articles describe the compensations in gait caused by limb-length discrepancy (LLD). Song and colleagues explored kinematic and kinetic variables utilizing work equalization as a marker of successful compensation for LLD. They found no difference in strategies based on the location of pathology. The purpose of this study was to define the various gait patterns in patients with LLD and the impact of these compensations on gait kinetics. METHODS:: Forty-three children (mean age 12.9±3.7 y) with LLD >2 cm were evaluated in the motion lab using a VICON motion system with 2 AMTI force plates. Etiologies included Legg-Calve-Perthes, developmental hip dysplasia, growth plate damage due to infection or trauma, congenital shortening of the femur or tibia, and syndromes creating shortening of the limb. Evaluation included physical examination and 3-dimensional motion data generated using the model described by Vicon Clinical Manager (VCM). For data analysis, 3 representative trials were processed with the Plug-in Gait lower-body model using the "VCM spline" filter. Walking strategies were identified by visual review. A kinematic threshold of 2 SD away from normal values was used for inclusion in each group. Strategies included: (1) pelvic obliquity with the short side lower (5.2degrees); (3) plantarflexion of the ankle on the shorter leg through the gait cycle (RESULTS:: Distribution of single strategies for the group included: pelvis (11), equinis (5), vaulting (7), knee flexion (3); 17 subjects used multiple strategies. If the discrepancy was in the femur, patients chose a more distal compensation strategy, utilizing ankle movements, which resulted in more work at the ankle joint on the short limb compared with normal (PCONCLUSIONS:: Our study contradicts previous literature that found no difference in strategy on the basis of location of the shortening and also a higher number of children with pelvic obliquity than previously described. It appears that different compensation schemes are used by patients with LLD. The increase in work may have long-term implications for management. Future studies will include changes in kinematics and work, after intervention. Better understanding of postoperative changes from different surgical methods may provide more insight for preoperative planning and may lead to a more satisfactory outcome for specific patients. LEVEL OF EVIDENCE:: Level II. Language: en

Correlation of Pirani and Dimeglio scores with number of Ponseti casts required for clubfoot correction

Abstract: Background A number of grading systems for severity of clubfoot have been reported in the literature, but none are universally accepted. The aim of this study was to find the correlation between 2 of the most widely utilized classification systems (the Pirani score and the Dimeglio score) with number of Ponseti casts required to achieve initial clubfeet correction. Methods A retrospective study of prospectively collected data was performed. All clubfeet assessed at our dedicated clubfoot clinic from January 2007 to December 2011 were included. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score. The total number of casts was calculated from the first cast to the time of initiation of the foot abduction orthosis. Results The mean number of Ponseti casts required to achieve initial correction was 5.8 (range, 2 to 10 casts). A low correlation (rs 0.21) was identified when the total Dimeglio score was compared with the number of casts. No correlation (rs 0.12) was identified between the Pirani score and the number of casts. Conclusions The Dimeglio and Pirani scores remain the most widely accepted clubfoot severity grading systems. However, their prognostic value remains questionable, at least in the early treatment stages. Level of evidence Prognostic study level II.

Fractures from trampolines: results from a national database, 2002 to 2011.

Abstract: BACKGROUND:: No study specifically analyzes trampoline fracture patterns across a large population. The purpose of this study was to determine such patterns. METHODS:: We queried the National Electronic Injury Surveillance System database for trampoline injuries between 2002 and 2011, and the patients were analyzed by age, sex, race, anatomic location of the injury, geographical location of the injury, and disposition from the emergency department (ED). Statistical analyses were performed with SUDAAN 10 software. Estimated expenses were determined using 2010 data. RESULTS:: There were an estimated 1,002,735 ED visits for trampoline-related injuries; 288,876 (29.0%) sustained fractures. The average age for those with fractures was 9.5 years; 92.7% were aged 16 years or younger; 51.7% were male, 95.1% occurred at home, and 9.9% were admitted. The fractures were located in the upper extremity (59.9%), lower extremity (35.7%), and axial skeleton (spine, skull/face, rib/sternum) (4.4%-spine 1.0%, skull/face 2.9%, rib/sternum 0.5%). Those in the axial skeleton were older (16.5 y) than the upper extremity (8.7 y) or lower extremity (10.0 y) (PCONCLUSIONS:: Trampoline fractures most frequently involve the upper extremity followed by the lower extremity, >90% occur in children. The financial burden to society is large. Further efforts for prevention are needed. Language: en

Potential causes of loss of reduction in supracondylar humerus fractures.

Abstract: Background Recent biomechanical studies have evaluated the stability of various pin constructs for supracondylar humerus fractures, but limited data exist evaluating these constructs with clinical outcomes. The goal of this study was to review the surgical management of Gartland type II and III supracondylar fractures to see whether certain pin configurations increase the likelihood of loss of reduction (LOR). Methods A total of 192 patients treated with a displaced supracondylar fracture were evaluated. LOR was defined as a change >10 degrees in either plane from its intraoperative reduction. Fracture classification, comminution, and location were documented. Intraoperative films were assessed for number of pins, location of pins both medial and lateral, bicortical purchase, pin spread at the fracture site, and pin divergence. Results Ninety-four patients had type II fractures, and 98 had type III fractures. The average patient age was 5.7±2.3 years. Extension-type injuries represented 98% of fractures. LOR was noted in 4.2% of patients. Age (P=0.48) and sex (P=0.61) were not associated with LOR. Fracture characteristics including type (P=0.85), comminution (P=0.99), and location (P=0.88) were not associated with LOR. Fractures treated with lateral-entry pins only or with 2 pins were no more likely to lose reduction (P=0.88 and 0.91). Pin spread at the fracture site was associated with LOR with less spread increasing the likelihood of failure (P=0.02). Fractures that lost reduction had an average pin spread of 9.7 mm [95% confidence interval (CI), 6.3-13.2) or 28% (95% CI, 26-31) of the humerus width compared with 13.7 mm (95% CI, 13-14.4) or 36% (95% CI, 13-60) of the humerus width for those that remained aligned. Conclusions LOR after percutaneous fixation of supracondylar fractures occurs relatively infrequently at a rate of 4.2%. This study suggests that pin spread is an important factor associated with preventing LOR with a goal of pin spacing at least 13 mm or 1/3 the width of the humerus at the level of the fracture. Level of evidence Retrospective study; level II.

The pediatric fracture of the scaphoid in patients aged 13 years and under: an epidemiological study.

Abstract: Background: Fractures of the scaphoid are uncommon in thepediatric population. Despite their rarity, a significant numberof children are referred to the fracture clinic for a suspectedscaphoid fracture. The aim of this study was to report on thecurrent incidence, pattern of injury, and the long-term outcomesfollowing this injury in the pediatric population.Methods: Analysis of all pediatric scaphoid fractures presentingto a tertiary pediatric hospital (aged 13y and under) over a5-year period was performed. The case notes, radiographs, andother imaging studies for these patients were reviewed. Long-term functional outcome was assessed using Disabilities of theArm, Shoulder and Hand (DASH) questionnaire.Results: Fifty-six patients of the 838 (6.7%) referred for a sus-pected scaphoid fracture were identified as having a confirmeddiagnosis of a scaphoid fracture, giving an average annual in-cidence of 11 per 100,000. This group consisted of 39 boys(70%) and 17 girls (30%). The average age of incidence in boyswas 12.2 years and in girls was 10.3 years (P<0.001). No sca-phoid fractures were observed in boys below the age of 11 yearsand in girls below the age of 9 years. The most common type offracture was a distal pole fracture (45 patients). One patientsustained a proximal pole fracture and went on to develop anonunion. The duration of treatment in cast was shorter indistal pole fractures than in other types (P<0.001). At a meanfollow-up of 70 months (range, 46 to 104mo), 60% reported nolimitation or impact when reporting a range of daily functionalactivities (mean DASH score=3.0).Conclusions: There is a suggestion that the overall incidence ofscaphoid fractures in the pediatric population is increasing, butchildren aged 13 years and under continue to maintain a distinctfracture pattern when compared with adolescents and adults.The majority involves the distal third of the scaphoid and carriesa good prognosis with conservative management.Level of Evidence: Prognostic study, Level 4.Key Words: pediatric, scaphoid fracture, epidemiology, func-tional outcome(J Pediatr Orthop 2014;34:150–154)

Epidemiology, Diagnosis, and Treatment of Pericapsular Pyomyositis of the Hip in Children

Abstract: Background: The yield of synovial fluid cultures in patients meeting clinical criteria for septic hip arthritis remains low. In the presence of positive blood cultures, these patients are diagnosed and treated as “presumed septic arthritis.” We hypothesized that some of these patients may instead have an extraarticular infection, such as pericapsular pyomyositis. Methods: An IRB-approved prospective study of children with suspected septic hip arthritis at a tertiary care children’s hospital over a 2-year time period was conducted. Children were evaluated with a previously published clinical algorithm with the addition of magnetic resonance imaging (MRI). Results: Of the 53 patients presenting with an acutely irritable hip, 32% were found to have pericapsular pyomyositis, whereas 15% were diagnosed with septic arthritis. Although C-reactive protein (CRP, Z33.1 mg/L) performed well at predicting infection, there were no significant differences in CRP, erythrocyte sedimentation rate, white blood cell count, temperature, or weight-bearing status in children with septic arthritis compared with pericapsular pyomyositis. In addition to MRI, there was a difference in the size of hip effusion on ultrasound, which was significantly smaller in cases of pericapsular pyomyositis. CRP (Z74.3 mg/L) was found to be predictive of need for surgical intervention in children with pericapsular pyomyositis. Conclusions: Correct anatomic diagnosis of the site of infection is essential for the efficient care of the child. Herein, we found that pericapsular pyomyositis is twice as common as septic arthritis in children presenting with an acutely irritable hip. Clinical algorithms are incapable of differentiating these pathologies suggesting that both be considered under the current diagnosis previously referred to as “presumed septic arthritis.” Incorrect diagnosis of a septic arthritis in the presence of a pericapsular pyomyositis could potentially lead to unnecessary debridement of the joint in the presence of extra-articular infection, thus contaminating the joint. Conversely, debriding the joint instead of the epicenter of the infection can prolong the infectious process. For these reasons, we conclude that MRI has the potential to improve the clinical care of children by providing a more precise diagnosis. Level of Evidence: Level II—“Diagnostic” [Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard)].

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows.

Abstract: Background:The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow

Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study.

Abstract: Background A prospective, randomized study examined the effect of interventional preoperative education and orientation for scoliosis surgery (PEOSS) on anxiety levels of patients undergoing posterior spinal fusion (PSF). Secondary outcomes analyzed were caregiver anxiety, length of stay, morphine equivalent usage, and patient/caregiver satisfaction. Methods Patients undergoing PSF were randomly distributed into a control group (N=39) or interventional group (N=26). All subjects and caregivers completed the State (current)-Trait (typical) Anxiety Inventory (STAI) at different intervals: preoperative appointment, preoperative holding area, postoperative orthopaedic unit, and discharge. At discharge, patients and caregivers completed a satisfaction survey. Results Significantly higher state anxiety scores were found compared with baseline at all time intervals in both the control group and PEOSS group. The PEOSS group had higher state anxiety scores than the control group at the postoperative interval (P=0.024). There were no significant differences in the caregiver state anxiety scores between the groups at any time interval. Trait anxiety scores for both groups remained stable over time, establishing that the measurement tool accurately reflected baseline anxiety. No significant differences were found in length of stay or morphine equivalent use. Patient satisfaction scores were higher in the PEOSS group than in the control group (P=0.0005). Conclusions PSF was associated with increased anxiety at all time intervals in adolescents in both groups. In the PEOSS group, PSF was associated with increased anxiety in the immediate postoperative period. Despite the increase in anxiety, patient satisfaction was higher in the intervention group. It is likely that patients need age-appropriate information and educational strategies to minimize anxiety during PSF. Further work is underway to study and develop more effective interventional strategies. Level of evidence Level I study.

Nighttime Bracing Versus Observation for Early Adolescent Idiopathic Scoliosis

Abstract: Background: Spinal bracing is widely utilized in patients with moderate severity adolescent idiopathic scoliosis with the goal of preventing curve progression and therefore preventing the need for surgical correction. Bracing is typically initiated in patients with a primary curve angle between 25 and 40 degrees, who are Risser sign 0 to 2 and 25 degrees primary curve Cobb angle. Curve progression was monitored with minimum 2-year follow-up. Results: Sixteen patients in the observation group and 21 patients in the bracing group completed 2-year follow-up. All patients in the observation group progressed to fulltime bracing threshold. In the nighttime bracing group, 29% of the patients did not progress to 25 degrees primary curve magnitude. Rate of progression to surgical magnitude was similar in the 2 groups. Conclusions: Risser 0 patients presenting with mild idiopathic scoliosis are at high risk for progression to >25 degrees primary curve magnitude. Treatment with the Charleston nighttime bending brace may reduce progression to full-time bracing threshold. No difference in progression to surgical intervention was shown between nighttime bracing and observation for small curves. Level of Evidence: Level II—therapeutic study (prospective comparative study).

Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?

Abstract: Background:Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, la

Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.

Abstract: BACKGROUND There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. METHODS In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. RESULTS CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. CONCLUSION CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.

The relationship between cam lesion and physis in skeletally immature patients.

Abstract: BACKGROUND Although it has been postulated that injury to the proximal femoral physis results in the formation of a cam lesion, a clear causal association has not been established. PURPOSE The purpose of this study was to investigate the relationship between the physis and the cam lesion. Our hypotheses were that (1) the location of the cam lesion would coincide with the growth plate and (2) the distance between the cam lesion and the physis would vary as a function of skeletal maturity. METHODS A retrospective review of the charts and magnetic resonance images of adolescent patients with femoroacetabular impingement (FAI) was performed. Data collected included the alpha angle, the distance between the cam lesion and physis, and physeal status. Linear mixed models were used to describe the association between the distance to the cam lesion and physeal status. RESULTS Twenty-four hips in 17 patients were included. The average alpha angles were 50.7, 63.2, 64.4, and 63.9 degrees for the anterior, anterosuperior, superoanterior, and superior radial magnetic resonance imaging sections. The average distance from the cam lesion to the physis was 0.07 cm. There was a significant association between physeal status and the distance of the cam lesion to the physis. CONCLUSIONS The location of the cam lesion occurs at the level of the physis. In skeletally mature adolescents, the cam lesion is located further from the physis than it is in patients whose growth plates remain widely open. This suggests a possible causal relationship between physeal injury and the development of the cam deformity in patients with femoroacetabular impingement. LEVEL OF EVIDENCE Level IV-retrospective case series.

A retrospective review of femoral nerve block for postoperative analgesia after knee surgery in the pediatric population

Abstract: Background To investigate the outcomes of pediatric patients receiving a femoral nerve block (FNB) in addition to general anesthesia for arthroscopic knee surgery compared with those receiving general anesthesia alone. Methods This retrospective review included all patients undergoing arthroscopic knee surgery from January 2009 to January 2011 under general anesthesia both with and without a FNB. After the induction of general anesthesia, those patients selected for regional anesthesia received a FNB using real-time ultrasound or nerve stimulator guidance. For the FNB, 0.2 to 0.4 mL/kg of local anesthetic solution was injected around the femoral nerve at the level of the inguinal crease. Intra-articular injection of bupivacaine (0.25%, 10 mL) was administered by the surgeon for all patients not receiving a FNB. Additional analgesic medications, PACU length of stay, duration of hospitalization, hospital course, and any acute or nonacute complications were recorded and evaluated. Results There were no adverse effects related to the FNB. Using a 0 to 10 visual analogue scale (0=no pain), there was a statistically significant difference in both the high (4.0 ± 4.0 vs. 5.3 ± 3.1, P=0.0004) and low (1.5 ± 1.8 vs. 2.1 ± 2.0, P=0.002) pain scores in patients who received a FNB versus those who did not with the scores being lower in those who had received a FNB. There was a decreased need for the use of opioids postoperatively (61% vs. 71%, P=0.04) and a decreased duration of postoperative stay in patients who were admitted to the hospital (11.7 ± 8.1 vs. 15.8 ± 10 h, P=0.044) in individuals who had a FNB. There was a significantly lower admission rate in patients undergoing anterior cruciate ligament repair in the FNB group (72% vs. 95%, P=0.001). There was no difference in the incidence of postoperative nausea and vomiting between the groups. Conclusion After arthroscopic knee surgery in pediatric patients, a FNB shortens hospital stay, reduces opioid requirements, and decreases postoperative pain scores. For anterior cruciate ligament repairs, FNB lowers postoperative admission rates. Clinical evidence Level III.

Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications?

Abstract: Background Because of the changing referral patterns, operative pediatric supracondylar humerus fractures are increasingly being treated at tertiary referral centers. To expedite patient flow, type II fractures are sometimes pinned in a delayed manner. We sought to determine if delay in surgical treatment of modified Gartland type II supracondylar humerus fractures would affect the rate of complications following closed reduction and percutaneous pinning. Methods We performed a retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. Mean patient age in the type II group was 5 years (range, 1 to 15 y). A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury. Results No difference was in detected in rates of major complications between the early and delayed treatment group. Four percent of patients sustained a complication (16 patients). There were no compartment syndromes, vascular injuries, or permanent nerve injuries. Complications included nerve injury (3), physical therapy referral for stiffness (3), pin site infection (2 treated with oral antibiotics, 4 treated with debridement), refracture (2), and loss of fixation or broken hardware (2). Of the 3 patients who sustained nerve injuries, all underwent surgery within 24 hours of injury. One patient developed an ulnar motor and sensory nerve palsy after fixation with crossed K-wires. This resolved by 7 weeks postoperatively. Two patients presented with an anterior interosseous nerve palsy-1 resolved 1 week after surgery, the other by 8 weeks postoperatively. Conclusions Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children. Further prospective work is necessary to determine if there are subtle treatment benefits from emergent treatment of type II supracondylar humerus fractures. Level of evidence Level III-retrospective comparative series.

Posterior sternoclavicular joint injuries in skeletally immature patients.

Abstract: Background:Posterior injuries to the sternoclavicular (SC) joint are uncommon. In the skeletally immature (SI) population, these injuries have been described as either dislocations of the SC joint or fractures of the medial clavicular physis. The current literature and standardized test questions st