Traditional Versus Water-resistant Short Leg Casting: A Randomized Controlled Pilot Study.

INTRODUCTION: We conducted a randomized controlled trial comparing fiberglass short leg casts with traditional cast padding to similar casts with water-resistant cast padding and recorded the opinion of the patient/caregiver and Orthopaedic Technicians (Ortho Techs) that applied and removed the casts. METHODS: Subjects with an injury that would be treated with a short leg cast were enrolled and randomized into a traditional cast or a water-resistant cast. Following cast application, the Ortho Tech that applied the cast completed a questionnaire asking their opinion on ease of application, moldability, padding level, and time taken for application. Following the removal of the study cast, the Ortho Tech that removed the cast completed a questionnaire that included an assessment of skin condition and evidence of the patient poking items inside the cast, as well as their opinion of ease of padding removal, padding durability and longevity, and an overall quality assessment of the cast padding. Following cast removal, the patient (or caregiver) also completed a questionnaire asking for their assessment of comfort, the weight of the cast, itchiness, heat/sweat, smell, and satisfaction. Patients who were treated with an expanded polytetrafluoroethylene cast were also asked about their happiness with the cast's water resistance and asked how long the cast took to dry. RESULTS: Sixty patients were included in this study, thirty in each group. The water-resistant casts took longer to apply than the traditional casts (12.4±4.0 vs. 8.2±3.2 min, P <0.001). The Ortho Techs favored the traditional cast when it came to ease of application ( P <0.001), moldability ( P =0.003), ease of padding removal ( P <0.001), padding durability ( P =0.006), padding longevity ( P =0.005), and their overall impression ( P =0.014). The patients/caregivers responded similarly among the 2 groups for each survey question. CONCLUSIONS: Patients randomized into each cast type tolerated their cast similarly; however, the Ortho Techs involved in this study preferred the traditional cast.

The Creation and Validation of an Ankle Bone Age Atlas and Data Predicting Remaining Ankle Growth.

BACKGROUND: The purpose of the current study was 2-fold: (1) to create and validate an ankle bone age atlas spanning the pediatric and adolescent years and (2) to utilize this atlas in conjunction with distal tibia/fibular growth data as measured on serial radiographs to develop a predictive growth model for the lower extremity. METHODS: Radiographs were surveyed to identify distinguishable, reproducible, radiographic features. Radiographic features of the tibia, fibula, hindfoot, and midfoot from 270 patients were identified and a "standard" for each age/sex was selected to create an atlas. A separate cohort of 90 ankle radiographs was selected to validate the atlas. A subcohort of 41 patients with left-hand radiographs within 3 months of ankle imaging was used to compare the 2 bone age approaches. Harris growth lines were evaluated in 304 serial images of the distal tibia to determine the remaining growth. RESULTS: The distal tib/fib ossification centers provided the best age assessment for early childhood (male age: 1 to 8 y; female age: 1 to 4 y). The ossification/fusion of the calcaneal apophysis provided the best age assessment in the preadolescent stage (male age: 6 to 14 y; female age: 5 to 12 y). The closure of the distal tib/fib physes best determined skeletal maturity (male age: 14 to 16 y; female age: 12 to 14 y). The ankle atlas had excellent interobserver and intraobserver reliability (intraclass correlation coefficient=0.993, P <0.001 and 0.998, P <0.001), respectively. We found an excellent correlation between the patient's chronologic age and ankle bone age ( r =0.984; P <0.001). Ankle bone age assessment and Greulich and Pyle were correlated ( rs =0.822, P <0.001). We found that males with a bone age of ≥15 years and females with a bone age of ≥13 years had ≤2 mm of residual growth of the distal tibia/fibula physes. CONCLUSIONS: bone age can be determined using ankle films ordered to assess/treat ankle injuries. This tool, along with our growth remaining table, may have important clinical implications when managing patients with ankle trauma with premature physeal closure. LEVEL OF EVIDENCE: IV.

Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis.

PURPOSE: To examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision. METHODS: A survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision -1 being "not important" and 5 being "very important". RESULTS: Four hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1-3, OR 3.38, p = .03. CONCLUSIONS: In this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.