Should isolated superolateral Hoffa's fat pad edema identified by MRI be reported or ignored in adolescent patients?

BACKGROUND AND OBJECTIVE: The presence of superolateral Hoffa's fat pad (SHFP) edema is associated with several morphometric measurements related to patellar alignment and trochlear morphology. Our aim is to evaluate management implications in adolescent patients with isolated superolateral Hoffa's fat pad edema on MRI. MATERIALS AND METHODS: Retrospective review of 117 adolescents with knee MRI (mean 14.8 years old) with isolated superolateral Hoffa's fat pad edema. Patients with edema were separated into two groups based on the number of MRI axial slices involved with edema: group 1 (G1) of 27 patients with 1 slice vs group 2 (G2) of 90 patients with 2 or more slices. A comparison control group was used (45 patients who had normal MRI knees). Data points included % referral for physical therapy (PT) or surgery, Hoffa's fat pad edema, tibial tubercle-trochlear groove (TT-TG) distance and lateral trochlear inclination (LTI) angle. Fisher's exact and independent t-tests, ANOVA and regression models were used for statistical analysis. RESULTS: There is statistically significant difference between Hoffa's fat pad edema patients and control regarding PT referral with G1: 70%, G2: 76%, and control: 53% (p = 0.03). There is statistically significant difference between these groups regarding TT-TG measurements with higher values in edema groups; G1: 11.9 mm±4.1, G2 13 mm ±4.1, and control 8.7 mm±3.6, (p = 0.001). There was a statistically significant association between edema and increased TT-TG distance (p = 0.001) but not LTI angle (p = 0.2). CONCLUSION: MRI identification of isolated superolateral Hoffa's fat pad edema is positively associated with TT-TG distance and its presence is associated with higher referral rates to physical therapy for patella maltracking.

Infection and Nonunion Following Operative Treatment of Lateral Humeral Condyle Fractures.

BACKGROUND: Lateral humeral condyle fractures (LHCF) are the second most frequent type of pediatric elbow fracture. The purpose of this study is to characterize infections and nonunions of LHCF treated at a single institution. This is the largest series on infections and nonunions of LHCF to date. METHODS: Pediatric patients undergoing surgical treatment for a LHCF from 2012 to 2022 at a single children's hospital were identified for a retrospective review. Patients who were diagnosed with an active infection or nonunion after surgery were included. Data collected included demographics, original treatment course, presentation, effective treatments, outcomes, and timing of events. RESULTS: Out of 863 surgical patients, 12 (1.4%) patients developed 13 infections: 8 were diagnosed with superficial cellulitis, 3 with soft tissue infections, and 2 with osteomyelitis. Eleven fractures were stabilized with percutaneous pins and 1 with buried pins. The average time to infection diagnosis was 29 days and the most common presenting symptom was increased or new onset of pain. All 12 patients received antibiotics for an average 18 days, 6 required hospital admission, 3 required surgical incision and drainage, and 2 required intravenous antibiotics without admission. One patient that developed osteomyelitis developed a nonunion. Ten (1.2%) surgical patients developed nonunion. There were 3 Weiss type II fractures and 7 type III fractures. On average, nonunions were diagnosed 12 weeks after initial treatment. Nine patients underwent nonunion surgery, and all went on to union. Patient's elbows were immobilized for an average 16 weeks and at least 5 patients required an average of 10 physical therapy sessions to regain their range of motion. CONCLUSION: Infection and nonunion are rare complications of LHCF, but greatly change the timeline and number of healthcare interactions required for healing. Infectious complications typically require admission, additional surgery, or emergency department visits. Nonunions require extensive cast time, additional surgery, and rehabilitation. LEVEL OF EVIDENCE: Level IV - case series.

Elbow injuries in the young athlete--an orthopedic perspective.

Elbow injuries in young athletes are increasing with these athletes specializing in a single sport at an early age and participating in their chosen sport at a high level year-round. The majority of these injuries occur from valgus loading of the elbow, either repetitively causing an overuse injury or more acutely resulting in a fracture or dislocation. Capitellar osteochondritis dissecans, medial epicondyle injuries and ulnar collateral ligament injuries are three of the most common elbow injuries occurring in young athletes.

Shoulder injuries in young athletes.

With increasing levels of competition at earlier ages, young athletes are becoming more susceptible to shoulder injuries. Overuse injuries in throwers are common conditions seen in pediatric and adolescent athletes. Little League shoulder and superior labial injuries are common due to the repetitive and high rotational forces placed on the shoulder during the throwing motion. Shoulder instability as a result of traumatic events occurring in collision sports is another frequent reason for young athletes to present to a sports medicine clinic. Although no operative treatment is often the first-line treatment for most of these injuries, shoulder surgery is becoming increasingly warranted in these young patients. Advanced cross-sectional imaging is important in guiding treatment for many of these injuries.

MRI findings in adolescent patients with acute traumatic knee hemarthrosis.

BACKGROUND: Physical examination may be inconclusive in adolescents presenting with an acute traumatic knee effusion because of pain and guarding. The purpose of this study was to describe the magnetic resonance imaging (MRI) findings in adolescents with traumatic knee effusions and to compare injuries based on age, sex, and physeal maturity. METHODS: All MRIs using a knee trauma protocol performed at our institution over a 2-year period were evaluated. One hundred thirty-one patients between the ages of 10 to 18 years of age with a clinical history of acute knee trauma and an effusion confirmed on MRI met our study inclusion criteria. They were divided into 2 age groups: 10 to 14 and 15 to 18 years old. Pathology was confirmed using clinical history, MRI, and any available surgical reports. RESULTS: Of the 131 patients with an acute knee effusion, there were 59 patients in the younger group (10 to 14 y old) and 72 patients in the older group (15 to 18 y old). In the younger group, patellar dislocations (36%), anterior cruciate ligament (ACL) tears (22%), and isolated meniscus tears (15%) were the most common injuries. In the older group, ACL tears (40%), patellar dislocations (28%), and isolated meniscus tears (13%) were the most common injuries. ACL injuries represented 28% of injuries in males and 38% of injuries in females, whereas patellar dislocations represented 28% of injuries in males and 37% of injuries in females. There was a trend toward adolescents with active growth plates sustaining more patellar dislocations and adolescents with closed growth plates sustaining more ACL injuries. Forty-one percent of patients in this study underwent surgery. CONCLUSIONS: Patellar dislocation is a common injury in children who present with a traumatic knee effusion, especially in young adolescents and females. Adolescents presenting with a traumatic knee effusion should undergo MRI because of the high rate of positive findings missed by physical examination and plain radiographs that may warrant surgical repair or reconstruction. LEVEL OF EVIDENCE: Level III.

The reliability to determine "healing" in osteochondritis dissecans from radiographic assessment.

BACKGROUND: Current literature supporting treatment strategies for osteochondritis dissecans (OCD) has limited prognostic utility. Presently, there is no gold standard for an OCD "healing" outcome. Accurate and reliable determination of the OCD healed status on the basis of radiographs would be valuable to provide a guide for evidence-based treatment of OCD. The purpose of this study was to determine interrater and intrarater reliability of radiographic assessment of OCD lesion healing in the knee. METHODS: A hospital database identified 39 consecutive patients with OCD in 42 knees, who were treated conservatively for at least 6 months. Patients were an average age of 11.9 years (±2.4 y). A total of 102 presentation slides were prepared, each containing 2 similar radiographic views from the same patient taken 6 months (±1 mo) apart. These slides were then categorized by 4 reviewers (1 orthopaedic surgeon, 1 orthopaedic fellow, and 2 musculoskeletal radiologists) blinded to patient data, as healed, not healed, or unable to evaluate the OCD lesion. Reviewers repeated their assessment at a minimum of 3 weeks after their first read. Intrarater and interrater reliability were measured with the Cohen κ coefficient and Randolph's free-marginal multirater κ, respectively, and with the percent agreement. RESULTS: OCD lesion categorization demonstrated insufficient interrater reliability with a κ of 0.44 and 63% agreement. The notch view had the highest interrater reliability with a κ of 0.63% and 76% agreement, and the lateral view had the lowest interrater reliability with a κ of 0.29% and 53% agreement. The OCD lesion categorization demonstrated substantial intrarater reliability with a κ of 0.68% and 81% agreement. CONCLUSIONS: Reviewers did not consistently agree on the "healing" status of the OCD lesions on the basis of radiographic assessments. Standard criteria to assess healing are needed to consistently evaluate OCD knee lesions in children. LEVEL OF EVIDENCE: Not applicable.

Growth plate fractures of the distal femur.

Growth plate fractures of the distal femur are challenging to treat, with complications that require a secondary surgery 40% to 60% of the time. These fractures often necessitate operative intervention, even in the youngest patients and even with minimal apparent displacement. Treatment varies with the Salter-Harris (SH) classification and with the extent of initial displacement, ranging from simple casting for nondisplaced SH I fractures to open reduction and internal fixation for almost all SH III and IV fractures. Poor outcomes have been associated with pediatric fracture care of SH III and IV in 29% to 32% of cases. There are many pitfalls that have to be avoided in the treatment of these fractures to prevent malunion, growth arrest, and posttraumatic arthritis.

Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability.

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.