Impact of Screening and Co-located Parent Coaching Within Pediatric Primary Care on Child Health Care Use: A Stepped Wedge Design.

Childhood adversity and toxic stress have been associated with poor mental and physical health. This study examined if Parent Connext, a program that integrates adversity screening and parent coaching by co-located specialists within pediatric primary care, had an impact on health care utilization. This stepped wedge cluster randomized controlled trial evaluated Parent Connext across six pediatric primary care practices. All practices (clusters) were in the control period during year 1. Three practices were randomized to begin the Parent Connext intervention in year 2, and three practices were randomized to begin in year 3. Medical records of all patients under age 8 treated at these practices during these 3 years were queried retrospectively for participant-level primary outcomes (sick visits, emergency department visits, hospitalizations) and secondary outcomes (well-child and immunization adherence, referrals). The study sample included 27,419 patients followed for an average 1.39 (SD = 0.66) years in the control period and 1.07 (SD = 0.60) years in the intervention period. During the intervention period, patients had significantly fewer sick visits (IRR = 0.91, p < 0.001) which aligned with our hypothesis, decreased odds of well-child visit adherence (OR = 0.88, p < 0.001) which was unexpected, and increased odds of receiving a referral (OR = 1.45, p < 0.001). The odds of an emergency department visit, hospitalization, and 2-year immunization adherence did not differ between periods. Parent Connext resulted in a significant reduction in child sick visits, highlighting the potential benefit of two-generation approaches to pediatric care for child health.

Identification of Initial and Subsequent Injury in Young Infants: Opportunities for Quality Improvement in the Evaluation of Child Abuse.

METHODS: Six children's hospitals identified infants with an initial injury and recurrent injury over a 1-year period using 2 methods: (1) diagnostic code method - infants 6 months or younger presenting with at least 1 diagnostic code for injury were tracked for 12 months to determine the frequency of recurrent injury, and (2) consult method - all available medical records of children 18 months or younger seen for an inpatient consultation for suspected child abuse were reviewed to identify history of a first injury at 6 months or younger. RESULTS: Using the diagnostic code method, 682 unique infants were identified with initial injuries, most commonly fractures (37.0%), bruising/ecchymosis (35.9%), and superficial injuries (28.3%). Forty-two infants (6.2%) returned with a second injury, and no demographic factors were significantly associated with the likelihood of a second injury. Using the consult method, 37 of 342 consults (10.8%) were identified as having a history of at least 1 initial injury. Of the initial injuries identified, the most common was bruising/ecchymosis (64.9%). The number of injuries identified with either method varied significantly across hospitals, as did completion of skeletal surveys for infants with bruising (range, 4.5%-71.1%; P < 0.001) and any injury (range, 4.4%-62.7%; P < 0.001). CONCLUSIONS: Our study demonstrates that young infants who experience 1 injury often experience a second injury. There exists significant variability in the identification of injury and the completion of skeletal surveys across a network of 6 children's hospitals. A standardized quality improvement approach may improve identification of injury and reduce the variability in practice observed.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition.

OBJECTIVES: To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS: Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS: Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS: About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants.

OBJECTIVES: The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse. METHODS: A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation. RESULTS: A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation. CONCLUSIONS: Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.

Parental Adverse Childhood Experiences and Pediatric Healthcare Use by 2 Years of Age.

OBJECTIVE: To determine whether maternal and paternal exposure to adverse childhood experiences (ACEs) has an association with offspring healthcare use by 2 years of age. STUDY DESIGN: A retrospective cohort study was performed on 454 patients at a large suburban pediatric primary care practice whose mother (n = 374) or father (n = 156) or both (n = 123) completed an ACE survey between October 2012 and June 2014. The association between self-reported parental ACEs and healthcare use by 2 years of age, including number of missed well-child visits, sick visits, and delayed or missed immunizations, was modeled using multivariable negative binomial regression. All analyses adjusted for child sex, payer source, and preterm birth. RESULTS: Maternal, but not paternal, ACE exposure was significantly associated with missed well-child visits by 2 years of age. For each additional maternal ACE, there was a significant 12% increase in the incidence rate of missed well-child visits (relative risk, 1.12; 95% CI, 1.03-1.22; P = .010). Maternal and paternal ACE scores were not significantly associated with increased sick visits or delayed or missed immunizations. CONCLUSIONS: The ACE exposure of mothers is negatively associated with adherence to preventive healthcare visits among their children early in life. Future research is needed to elucidate the mechanisms of this association and to develop and implement family-based intervention strategies.

Maternal Interpersonal Trauma and Child Social-Emotional Development: An Intergenerational Effect.

BACKGROUND: Evidence suggests that maternal interpersonal trauma can adversely affect offspring health, but little is known about potential transmission pathways. We investigated whether interpersonal trauma exposure had direct and indirect associations with offspring social-emotional development at 12-months of age in an at-risk, home visited population. METHODS: A retrospective cohort study was conducted of 1172 mother-child dyads who participated in a multi-site, early childhood home visiting program. Children were born January 2007 to June 2010 and data were collected at enrolment (prenatal/birth) through 12-months of age. Multivariable path analyses were used to examine the relationship between maternal interpersonal trauma, subsequent psychosocial mediators (maternal depressive symptoms, social support, and home environment), and the outcome of child social-emotional development measured with the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE). Maternal interpersonal trauma was characterized as any previous exposure, the level of exposure, and type (e.g. abuse) of exposure. RESULTS: The prevalence of maternal interpersonal trauma exposure was 69.1%, and exposures ranged from 1 type (19.3%) to 7 types (2.3%). Interpersonal trauma was associated with a 3.6 point (95% confidence interval 1.8, 5.4) higher ASQ:SE score among offspring and indicated greater developmental risk. An estimated 23.4% of the total effect was mediated by increased maternal depressive symptoms and lower social support. Differential effects were observed by the level and type of interpersonal trauma exposure. CONCLUSION: Maternal interpersonal trauma exposures can negatively impact child social-emotional development, acting in part through maternal psychosocial factors. Future research is needed to further elucidate the mechanisms of intergenerational risk.

Does using PAs in the closed treatment of pediatric forearm fractures increase malunion risk?

PURPOSE: This study assessed whether using physician assistants (PAs) for fracture follow-up during nonoperative management of pediatric forearm fractures was associated with an increased risk of malunion. METHODS: The study was a retrospective review of charts of 141 children under age 18 years who were treated nonoperatively in the division of orthopedics over 12 months for forearm fractures. The effect of type and number of follow-up providers on risk of malunion was determined and controlled for fracture type, location, and initial angulation. Logistic regression, Fisher exact test, and Cochran-Armitage trend test were used to analyze the data, with P < .05 indicating statistical significance. RESULTS: Using strict criteria, malunion was identified in 42 (30%) of 141 patients. Follow-up provided by even up to four PAs did not increase malunion risk. Transfer of care between two attending physicians increased malunion risk, independent of fracture characteristics. CONCLUSION: The involvement of even multiple PAs during follow-up management of nonoperatively treated pediatric forearm fractures is not associated with an increase in the risk of malunion. These findings are consistent with previous published works that highlighted the safe and valuable role PAs can play in the management of common fractures.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

Eccentric Capitellar Ossification Limits the Utility of the Radiocapitellar Line in Young Children.

BACKGROUND: The radiocapitellar line (RCL) has long been used for the radiographic evaluation of elbow alignment. In children, the capitellar ossific nucleus serves as a proxy for the entire capitellum, but this substitution has not been verified. Using magnetic resonance imaging (MRI), we sought to understand how maturation of the ossific nucleus of the capitellum affects the utility of RCL throughout skeletal maturation of the elbow. METHODS: The RCL was drawn on coronal and sagittal MRIs in 82 children (43 boys, 39 girls; age range, 1 to 13 y) with at least 3 patients in each 1-year interval age group. The perpendicular distance of the RCL from the center of both the cartilaginous capitellum and the capitellar ossific nucleus was measured relative to its total width, and a percent offset for each measurement was calculated. Logarithmic regression analysis was performed to analyze the effect of age and sex on percent offset. RESULTS: The RCL reliably intersected with the central third of the cartilaginous capitellum at all ages in both planes. Although the RCL intersected with the ossified capitellum in all but 3 measurements, it intersected with the central third of the ossified capitellum less often in younger children in both sagittal (B=0.47, P<0.001) and coronal (B=0.31, P=0.002) planes. Percent offset decreased significantly with age in a logarithmic manner in both sagittal (r=0.57, P<0.001) and coronal (r=-0.47, P<0.001) planes. 95% confidence intervals predict that the sagittal plane RCL will accurately intersect the central third of the ossified capitellum by age 10 years in girls and age 11 years in boys but not in the coronal plane. CONCLUSIONS: Eccentric ossification of the capitellum explains RCL variability in young children. The RCL does not reliably intersect the central third of the ossified capitellum until ages 10 years in girls and 11 years in boys in the sagittal plane. The RCL should be used within its limitations in skeletally immature children and should be combined with advanced imaging if necessary.

Elastic nailing for pediatric subtrochanteric and supracondylar femur fractures.

BACKGROUND: Subtrochanteric and supracondylar femur fractures are difficult injuries to treat in children. Although elastic stable intramedullary nails are commonly used for pediatric femur shaft fractures, there is little information on their effectiveness for managing pediatric subtrochanteric and supracondylar femur fractures. QUESTIONS/PURPOSES: We (1) evaluated radiographic union rates and fracture alignment after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, (2) identified complications, and (3) determined risk factors for complications. METHODS: Between 2005 and 2011, 36 subtrochanteric fractures and eight supracondylar femur fractures were treated with elastic stable intramedullary nails and had complete followup until clinical and radiographic union. Elastic nailing was used for subtrochanteric fractures in children 5 to 12 years of age or after failed spica cast treatment in younger children and for displaced supracondylar fractures in children older than 5 years. Fracture alignment and union were measured on radiographs, and complications were identified from review of patient charts. Patients with and without complications were compared using nonparametric tests to identify risk factors. RESULTS: All fractures healed; 23 of 33 (70%) subtrochanteric femur fractures and five of seven (71%) supracondylar femur fractures healed with anterior angulation of about 5°. For subtrochanteric fractures, complications included repositioning/removal of nails before radiographic union (n = 4), malunion (n = 2), fracture (n = 1), irritation (n = 1) at nail insertion site, and limb length discrepancy (n = 1); despite these complications, there were 22 (61%) excellent, 12 (33%) satisfactory, and only two (6%) poor outcomes. For supracondylar fractures, complications included infection after nail removal (n = 1) and nail site irritation (n = 2); there were three (38%) excellent, five (62%) satisfactory, and no poor outcomes. Complications were more likely after subtrochanteric fracture during motor vehicle accident (p = 0.045). CONCLUSIONS: Although complication rates are high with elastic nailing for pediatric subtrochanteric (22%) and supracondylar (38%) femur fractures, elastic nailing represents an important option for difficult-to-manage femur fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Hand function and quality of life in children with epidermolysis bullosa.

Patient-reported outcomes are becoming increasingly important to clinical care. Epidermolysis bullosa (EB), a rare genetic skin disorder, can result in severe hand impairment, but parent and patient perceptions of hand function have never been assessed. This study aimed to quantify parent- and patient-reported hand function and assess its relationship with quality of life (QOL) in children with EB. This cross-sectional study included children with EB treated at an interdisciplinary EB center. Hospital records were searched for demographic characteristics and medical history. Eligible families were invited to complete two surveys by mail or telephone. The ABILHAND-Kids questionnaire assessed manual hand ability for 21 functions. The Quality of Life in Epidermolysis Bullosa questionnaire assessed EB-related QOL. Hand function and QOL of various subtypes were compared using Mann-Whitney tests. Seventy-one parents and patients ages 2 to 18 years with EB from 20 states in the United States completed questionnaires. Children with recessive dystrophic EB reported the worst hand function and QOL. Bimanual functions involving finger mobility were the most challenging for all EB subtypes. QOL was highly related to the degree of hand function, being correlated with 20 of the 21 individual hand functions and most associated with the ability to perform unimanual functions. Parent- and patient-reported hand function can be measured in children with EB using the ABILHAND-Kids questionnaire. Hand impairment is strongly associated with worse QOL, probably due to difficulty performing daily activities. The effect of interventions such as hand surgery could be prospectively evaluated using this questionnaire.

MR imaging of capitellar ossification: a study in children of different ages.

BACKGROUND: The capitellar ossification center is used routinely to evaluate elbow alignment on radiography. However, whether capitellar ossification is central and concentric to support this practice is unknown. OBJECTIVE: To define the pattern of capitellar ossification at different ages of childhood. MATERIALS AND METHODS: This HIPAA-compliant study was IRB approved. MR imaging examinations from 81 children (ages 1-13 years, at least 3 boys and 3 girls in each age group) were included. We determined the center points of the ossified capitellum and the cartilaginous capitellum on the sagittal and coronal sequences that best showed differentiation between cartilage and bone. Percentage offset of the center of the ossified capitellum from the center of the cartilaginous capitellum was calculated in anterior-posterior, proximal-distal and medial-lateral dimensions, and compared across age groups and between genders. Linear regressions were used to ascertain the effect of age on percentage offset for all patients and for each gender. RESULTS: Capitellar ossification begins eccentrically with sagittal anterior proximal offset and coronal medial offset. With age, ossification proceeds posteriorly, distally and laterally. Percentage offset gradually diminishes with age. The ossified capitellum centralizes in the sagittal plane by 12-13 years. In the coronal plane, the capitellum ossifies medially beyond the proximal radioulnar joint and remains eccentric at 12-13 years. Centralization in boys lags in the anterior-posterior dimension. CONCLUSION: Capitellar ossification is an eccentric process, with lag in anterior-posterior centralization in boys. Medial offset persists at 12-13 years. Recognition of this eccentric ossification may allow for more accurate assessment of elbow alignment on radiographs, especially in younger children.

Absence of radiographic abnormalities in nursemaid's elbows.

BACKGROUND: Disagreement exists between physicians on the usefulness of a prereduction radiograph for diagnosis and treatment of nursemaid's elbows in children. Some evidence suggests that nursemaid's elbows have identifying features on radiographs. This study compares the radiographs of nursemaid's elbows to normal, control elbows in children and hypothesizes that differentiating features do not exist on radiograph. METHODS: For this retrospective case-control study, hospital billing records were searched to identify all patients under age 6 treated with closed reduction for a nursemaid's elbow between November 2005 and October 2009. Twenty-seven nursemaid's elbows were age-matched and sex-matched to 27 normal "comparison view," control elbows. Radiocapitellar line offset, proximal radial length, anterior fat pad angle, and visibility of the posterior fat pad were measured on the radiographs by 2 raters. Their interrater reliability was assessed with intraclass correlations, and the nursemaid's and control elbow measures were compared using Wilcoxon tests. RESULTS: Nursemaid's elbows and healthy control elbows did not differ significantly in offset of the radiocapitellar line from the capitellum center on anteroposterior (P=0.49) or lateral views (P=0.67), in proximal radial length (P=0.95), anterior fat pad angle (P=0.49), or posterior fat pad visibility (P=1.00) on lateral views. CONCLUSIONS: Nursemaid's elbows are indistinguishable from healthy elbows on radiograph. Thus, the term "radial head subluxation" appears to be a misnomer, and prereduction radiographs should only be used to eliminate the possibility of fracture. From a radiologic perspective, nursemaid's elbows remain a diagnosis of exclusion. LEVEL OF EVIDENCE: Therapeutic Level III-retrospective comparative study.

Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter?

BACKGROUND: Direct beam radiation exposure to the surgeon, especially to their hands, is extremely common during supracondylar humerus fracture pinnings and results in exposure to significantly greater doses of ionizing radiation when compared with scatter radiation. The purpose of this study was to determine how often surgeons are exposed to direct beam radiation during this surgery and whether the C-arm position and the surgeon's experience influence radiation exposure. METHODS: In this double blind study, we collected 3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon's body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded. Nonparametric statistical analyses were performed. RESULTS: Fluoroscopy lasted for a median of 34 seconds, and the surgeon was exposed to direct beam radiation in a median of 13% of fluoroscopy films, with exposure ranging from 0% to 97% per surgery. Fluoroscopy was significantly longer when the C-arm position was inverted when compared with the standard position (43 vs. 26 s, P=0.034). Surgeons' exposure to direct beam radiation was also slightly greater when the C-arm position was inverted (16% vs. 10%, P=0.087). The duration of fluoroscopy exposure and the percentage of films with the body exposed to radiation did not differ based on whether the surgery was performed by an attending, a resident, or both (P=0.53 and 0.28, respectively). However, the percentage of films with bodily radiation exposure did significantly differ between the attending physicians (P=0.029). CONCLUSIONS: Direct beam radiation exposure varied widely between surgeries and surgeons, ranging from none to nearly constant exposure. Surgical time also significantly increased with the C-arm in the inverted position compared with the standard position. Given the significant variation in exposure between attending physicians, it is likely that exposure to direct beam radiation can be avoided with improved awareness about the risk of direct beam radiation exposure and cautious surgical technique. LEVEL OF EVIDENCE: Not applicable.

The value of interpretation of intraoperative fluoroscopy by radiologists during pediatric fracture treatment.

BACKGROUND: Orthopaedic surgeons frequently use intraoperative fluoroscopy to aid in the real-time decision-making process during fracture treatment. Radiologists routinely interpret and report on these fluoroscopic images. The goal of this combined retrospective and prospective study was to assess the value of this practice of having radiologists interpret intraoperative fluoroscopy for pediatric fracture treatment. METHODS: In 500 consecutive pediatric patients who underwent fracture treatment in the operating room during a 1-year period, the following 4 parameters were retrospectively reviewed: (1) time between completion of procedure and availability of radiologist's report, (2) discrepancies between the surgeon-dictated operative report and the radiologist's report on the fluoroscopic images, (3) recommendations or unexpected findings in the radiologist's report, and (4) charges and reimbursement for the radiologist to report on the fluoroscopic images. In an additional 76 consecutive pediatric trauma patients, the number of intraoperative fluoroscopy images taken during fracture treatment and the number saved and sent to the radiologist were collected in a prospective and blinded manner. RESULTS: In 500 consecutive cases, 89% of radiologist reports were not available until after the end of the procedure. There was no discrepancy between the surgeon-dictated operative report on use of fluoroscopy and the radiologist's interpretation of the fluoroscopic images. Three (0.6%) patients had an unexpected finding on the radiologist's report but that did not change the fracture treatment. The mean charge by the radiologist was $166.96±11.84 and the mean reimbursement was $5.83±7.01. For the prospective arm of the study, 41.9% of all intraoperative fluoroscopy images taken were saved and sent to the radiologist. CONCLUSIONS: For the majority of procedures, the radiologist report was not available until after the end of the procedure. The radiologist's interpretation of intraoperative fluoroscopy did not alter fracture treatment in any patient. Because of limited benefit and low reimbursement, this study suggests that the practice of having a radiologist interpret intraoperative fluoroscopy during fracture treatment adds little value to patient care. LEVEL OF EVIDENCE: Decision Analysis Level II.

Does medial patellofemoral ligament reconstruction decrease patellar height? A preliminary report.

BACKGROUND: The purpose of this study was to evaluate the hypothesis that medial patellofemoral ligament (MPFL) reconstruction for patellar instability decreases patellar height. METHODS: Preoperative and postoperative lateral knee radiographs of 38 adolescents who underwent MPFL reconstruction between 2005 and 2011 were reviewed. The Insall-Salvati index, Blackburne-Peel index, Caton-Deschamps index, and plateau-patella angle were measured on all radiographs to identify differences in patellar height. These patellar height indices were also measured on lateral knee radiographs of 25 adolescents (control group) who were treated conservatively for osteochondritis dissecans of the knee. The 2 groups were compared to account for patellar height changes secondary to growth and ossification. Intrarater reliability was measured for all patellar height indices at 1-month interval. RESULTS: Preoperatively, patients who underwent MPFL reconstruction had significantly greater patellar height on all indices compared with the control group before and after controlling for age and sex. The patients who underwent MPFL reconstruction showed a significantly greater decrease in patellar height on the Blackburne-Peel or Caton-Deschamps indices over time compared with the control group such that postoperatively there was no difference between groups in these patellar height indices. Furthermore, the change in patellar height indices after MPFL reconstruction did not differ between patients with less than or more than 1-year follow-up. All indices demonstrated good to excellent intrarater reliability. CONCLUSIONS: The present study showed a decrease in patellar height in the postoperative period in patients after MPFL reconstruction for patellar instability. Further investigation is necessary to determine the long-term effects of MPFL reconstruction on patellar height. LEVEL OF EVIDENCE: Level III--therapeutic, case series.

Functional outcome analysis of triplane and tillaux fractures after closed reduction and percutaneous fixation.

BACKGROUND: There are limited data regarding the outcomes of triplane and tillaux fractures. The purpose of our study was to provide a long-term follow-up analysis of the functional outcomes as they relate to articular displacement using validated outcome tools. METHODS: A retrospective chart and radiographic review was performed to identify the age, the sex, the treatment method, complications, the fracture type, and articular displacement. Most patients underwent closed reduction with percutaneous fixation. We used 2 validated outcome measures, namely the Foot and Ankle Outcomes Score and the Marx Activity Scale, to assess functional results at a minimum of 2 years from the time of injury. RESULTS: We identified 78 patients between 2000 and 2009 who underwent computed tomographic scan evaluation of either a triplane (n=58) or a tillaux fracture (n=20). Triplane fractures occurred at a significantly younger age than tillaux fractures for both men and women (P=0.01). Women were found to suffer transitional fractures at a younger age than men (P<0.001). Patients with residual articular displacement of up to 2.4 mm after definitive treatment did not have worse functional outcomes compared with those who had an anatomic reduction on any of the Foot and Ankle Outcomes Score subscales and the Marx Activity Scale. Similarly, there was no correlation between the magnitude of residual gap or step-off with functional outcome when the gap and step-off are <2.5 mm. Patients with longer-term follow-up (>4 y) did not have deterioration of function compared with those with a follow-up of 2 to 4 years. CONCLUSIONS: Tillaux and triplane fractures have good medium-term outcomes after reduction and fixation. Using primarily closed reduction and percutaneous fixation techniques, patients with a residual displacement of <2.5 mm after treatment have a uniformly good result. Functional results do not deteriorate at longer-term follow-up (4 to 10 y) as long as adequate reduction has been achieved. Percutaneous fixation yielded uniformly good results on all scales. LEVEL OF EVIDENCE: Therapeutic level III.

Trochlear groove osteochondritis dissecans of the knee patellofemoral joint.

BACKGROUND: The trochlear groove is the rarest location for osteochondritis dissecans (OCD) of the knee, with only about 50 previously reported cases, most of which were treated before the advent of magnetic resonance imaging (MRI) and modern techniques of cartilage fixation or osteochondral transplantation. The purpose of this multicenter study was to assess the patient presentation and clinical, radiographic, and functional results of treatment for trochlear groove OCD lesions. METHODS: Hospital records from 5 institutions of the Research in Osteochondritis of the Knee (ROCK) study group were retrospectively reviewed for cases of trochlear groove OCD. Demographics, clinical presentation, diagnosis, treatment, time to pain resolution, and return to sports were recorded. Lesion appearance, size, stability, and time to radiographic healing were evaluated on plain x-rays and MRIs. RESULTS: Trochlear groove OCD lesions were evaluated in 24 knees in 21 adolescents (17 male, 4 female), with an average age of 14 years (range, 10 to 18 y). Fifty-four percent (13/24) of the lesions were identifiable on radiographs, and all were identifiable on MRI, 38% of which (9/24) was unstable. One fourth (6/24) of knees had coexistent femoral condyle OCD lesions. Treatment outcomes were evaluated in patients with a minimum of 1-year follow-up (average: 3 y; range: 1 to 12 y) or healing before 1 year. Half of the knees (2/4) treated nonoperatively and two thirds (8/12) treated operatively showed radiographic signs of healing with patients returning to full activity without pain. Operative treatment success rates were as follows: drilling (3/3), fixation (3/3), microfracture (1/2), drilling with subsequent delayed microfracture (1/1), and drilling with fixation (0/3). CONCLUSIONS: MRI aids in the diagnosis and staging of trochlear groove OCD lesions, as almost one half may not be identifiable on radiographs, and one quarter are associated with OCD lesions in other locations of the same knee. Multiple operative treatments can be used to achieve healing or resolution of symptoms in stable and unstable lesions; however, a larger comparative study is needed to make specific recommendations. LEVEL OF EVIDENCE: Therapeutic Level IV.

Limb Lengthening and Reconstruction Society AIM index reliably assesses lower limb deformity.

BACKGROUND: Although several systems exist for classifying specific limb deformities, there currently are no validated rating scales for evaluating the complexity of general lower limb deformities. Accurate assessment of the complexity of a limb deformity is essential for successful treatment. A committee of the Limb Lengthening and Reconstruction Society (LLRS) therefore developed the LLRS AIM Index to quantify the severity of a broad range of lower extremity deformities in seven domains. QUESTIONS/PURPOSES: We addressed two questions: (1) Does the LLRS AIM Index show construct validity by correlating with rankings of case complexity? (2) Does the LLRS AIM Index show sufficient interrater and intrarater reliabilities? METHODS: We had eight surgeons evaluate 10 fictionalized patients with various lower limb deformities. First, they ranked the cases from simplest to most complex, and then they rated the cases using the LLRS AIM Index. Two or more weeks later, they rated the cases again. We assessed reliability using the Kendall's W test. RESULTS: Raters were consistent in their rankings of case complexity (W = 0.33). Patient rankings also correlated with both sets of LLRS AIM ratings (r(2) = 0.25; r(2) = 0.23). The LLRS AIM Index showed interrater reliability with an intraclass correlation (ICC) of 0.97 for Trial 1 and 0.98 for Trial 2 and intrarater reliability with an ICC of 0.94. The LLRS AIM Index ratings also were highly consistent between the attending surgeons and surgeons-in-training (ICC = 0.91). CONCLUSIONS: Our preliminarily observations suggest that the LLRS AIM Index reliably classifies the complexity of lower limb deformities in and between observers.

Trends in pediatric sports-related and recreation-related Injuries in the United States in the last decade.

BACKGROUND: There is an apparent increase in pediatric sports and recreation (SR)-related injuries in the United States in the last decade. The aim of this study was to compare injuries in 2000 to injuries sustained in 2005 and 2010 to determine the trend in 8 most common pediatric SR-related injuries in the United States in the last decade. METHODS: The National Electronic Injury Surveillance System was queried for injuries sustained in the 5- to 14-year age group for the 8 most common SR-related activities for years 2000, 2005, and 2010. RESULTS: Compared with 2000, the musculoskeletal injuries decreased by 10.8% in 2005 and 12.4% in 2010 for the top 8 SR-related activities in children of 5 to 14 years. This corresponded with 13.2% (2005) and 1.1% (2010) decreases in all injuries. Controlling for total United States population of children of 5 to 14 years, the musculoskeletal injury incidence rate for all 8 SR-related activities decreased from 16.4/1000 person-year in 2000 to 14.4/1000 person-year in 2010. Sports-specific injuries decreased in 6 of 8 SR-related activities from 2000 to 2010. The maximal decrease was seen in bicycling (38.1%), roller sports (20.8%), and trampolines (17.5%). Football and soccer injuries increased by 22.8% and 10.8%, respectively. Compared with children aged 5 to 9 years, children aged 10 to 14 sustained a greater proportion of total injuries. CONCLUSIONS: The perception that pediatric SR injuries in the United States have increased in the last decade appears to not be true. The apparent misconception of an increased rate of injury may in fact be due to increased severity of injuries, overuse injuries, or increased diagnosis, but is not due to increase in the total number of acute injuries. Understanding the trend of pediatric SR-related injuries can help future injury-prevention efforts. LEVEL OF EVIDENCE: Level IV-prognostic study.