Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons.

INTRODUCTION: Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. METHODS: In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. RESULTS: Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. CONCLUSIONS: Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. LEVEL OF EVIDENCE: Level IV.

Preliminary Report: Pediatric Femur Fractures: Single Incision Intramedullary Stabilization Technique.

BACKGROUND: Pediatric femoral shaft fractures are common injuries that have seen a trend toward surgical stabilization. Traditionally these fractures have been stabilized with flexible intramedullary nails performed through a 2-incision technique. We proposed that a single incision technique would offer equivalent outcomes with the potential for improved cosmesis and a reduced infection risk. METHODS: A retrospective review was performed of 112 consecutive cases of pediatric femoral shaft fractures, 66 cases were excluded, leaving 23 cases utilizing the single incision technique and 23 utilizing the standard 2-incision technique. Electronic medical records were then reviewed for demographic information, and a PAC system was employed to classify the fractures according to the AO classification and determine the time to fracture union. RESULTS: No significant difference was found in fracture healing times with a mean union time of 62.4 and 50.3 days in the single and double incision groups, respectively (P=0.38). One complication of superficial infection was noted in the 2-incision group; however, this was not statistically significant, and no malunions or nonunions were detected in either group. CONCLUSIONS: A single incision technique for intramedullary stabilization of pediatric femoral shaft fractures is a viable option with an equivalent time to fracture union and no observed difference in the complication rate. Furthermore, the technique may offer benefits with regard to infection risk and cosmesis.

Pediatric Musculoskeletal Coccidioidomycosis in Central California: A Single Center Experience.

BACKGROUND: Published literature on musculoskeletal coccidioidomycosis is sparse and limited to case reports and case series. This is one of the largest case series to describe the clinical presentation, diagnosis, medical and surgical management and outcomes of pediatric musculoskeletal coccidioidomycosis at a tertiary care hospital. METHOD: A retrospective case review was performed on patients ≤ 21 years old who were followed at a tertiary care center with a diagnosis of musculoskeletal coccidioidomycosis from January 1, 2007, to December 31, 2020. Descriptive data are expressed as medians and interquartile range (IQR) for continuous variables or as frequency and percentage for categorical variables. Categorical values were compared using the χ2 test. RESULTS: Forty-one patients were identified. The median age was 12.8 years, and most were male (71%), Latinx (66%) and healthy (71%). Limb swelling (66%), bone pain (54%) and joint pain (46%) were the most common presenting symptoms. Multiple bone involvement was present in 29% while 12% had the joint disease, and craniofacial (n = 10) and metacarpal/metatarsal bones (n=9) were the most commonly involved sites. Elevated Coccidioides complement fixation (CF) titers ≥1:32 were seen in 90% of the patients. Thirty-three patients (81%) required surgical interventions and of these 16 (48%) required additional surgical procedures. Eleven patients (27%) had disease relapse. Children >13 years of age were more likely to have > 1 organ involvement (16 vs. 7, P = 0.04), multiple bone involvement (10 vs. 2, P = 0.004) and maximum Coccidioides CF titers >1:128 (13 vs. 6, P = 0.02). CONCLUSIONS: In endemic areas, musculoskeletal coccidioidomycosis causes a substantial disease burden in children and should be considered in the differential diagnosis of those presenting with bone and joint pain or swelling. Early diagnosis and treatment are essential to minimize long-term morbidity and mortality.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Single incision pediatric flexible intramedullary tibial nailing.

BACKGROUND: There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. METHODS: Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. RESULTS: All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. CONCLUSIONS: Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.

Opinion survey regarding pediatric orthopaedic trauma call and emergency trauma management.

BACKGROUND: To determine the attitudes and practices of pediatric orthopaedic surgeons regarding on-call coverage and emergency fracture management. METHODS: A 32-question online survey was sent to all 597 active members of the Pediatric Orthopaedic Society of North America. There were 296 completed surveys, for a response rate of 49.6%. RESULTS: Of the respondents, 85.1% were male. The respondents ranged in age from 30 to older than 70 years, with 54% between 36 and 50 years of age, corresponding to an average of 15 years in practice. Seventy-seven percent of the respondents felt that taking trauma call is an integral aspect of being a pediatric orthopaedist. Of the respondents, 64.9% take call 1 to 9 times per month, 15.8% take 10 to 19 calls, 2.7% take 20 or more, and 16.6% take no call. The number of orthopaedists taking call per practice was fairly evenly distributed between 3 and 10. Call was shared equally in 32% of practices, and mandatory in 72%. Twenty-eight percent of the respondents were additionally compensated for taking calls, in amounts ranging from $100 to $2000 per night, with 1000 dollars the most common rate. One third of operative cases are done that night; one third, the next day; and one third, later in the week. Twenty-four percent of the respondents have dedicated operative block time on the day after the call. Forty-seven percent have a dedicated fracture clinic, of which 51% receive institutional support. CONCLUSIONS: Providing emergency trauma care for children is an integral aspect of pediatric orthopaedics. This survey provides information on the attitudes and strategies of practicing pediatric orthopaedic surgeons in the face of decreasing manpower and increasing demand for such services.

Injuries when children reportedly fall from a bed or couch.

One-hundred-fifteen patients with orthopaedic injuries resulting from a reported fall from a piece of furniture at home were studied to define the relationship of suspected child abuse associated with this mechanism of injury. One hundred-thirteen patients sustained fractures or dislocations and two patients were impaled with a pencil and a needle. Each patient was evaluated by a primary care physician or an emergency room physician and by an orthopaedic surgeon. In six of 115 patients (5%), a treating physician filed a child abuse report. In 109 patients (95%) the purported mechanism of injury was considered sufficient to produce the resulting injury. Two of four children younger than 1 year (50%), four of 83 children 1 to 5 years (5%), and none of the 28 children older than 5 years were investigated for potential child abuse. Orthopaedic injuries reportedly attributable to a child falling from a bed or couch at home usually are accidental unless the child is younger than 1 year.