Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures.

BACKGROUND: Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal. METHODS: A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion. RESULTS: Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients. CONCLUSION: Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization. LEVEL OF EVIDENCE: III.

Neuromuscular Patients Are 40% More Likely to Get a Cast Injury.

BACKGROUND: Cast injuries can occur during application, throughout immobilization, and during removal, with common morbidities being pressure ulcers and cast saw burns. The incidence rate of cast injuries in generalized and diagnosis specific pediatric populations is not known. The goal of this study is to accurately quantify the rate of incidence of cast injuries at a large pediatric orthopaedic practice and identify potentially modifiable risk factors to guide quality of care improvement. METHODS: A retrospective review was performed at our institution between July 2019 and October 2020. Inclusion criteria was all pediatric patients (below 21 y old) with an orthopaedic diagnosis that was treated with casting. The child's diagnosis, specific type of cast, and training level of the person applying the cast was recorded. Patient injuries were identified through cast technicians' documentation regarding cast removal. The primary outcome was the incidence of casting injuries from July 2019 through October 2020. Additional outcomes included the association between diagnosis of neuromuscular disease and training level of individual applying the cast with casting injuries. χ2 tests were used to compare categorical variables and post hoc comparisons using Bonferroni correction. Injury incidence rates were calculated as number of injuries per 1000 casts. RESULTS: There were 2239 casts placed on children at this institution between July 2019 and October 2020 and a total of 28 injuries for an incidence rate of 12.5 per 1000. Of the 28 total injuries reported, there were 5 cast saw burns (2.2 per 1000) and 23 pressure ulcers (10.3 per 1000). Incidence of cast injury was not significantly correlated with timing of application during the academic year or training level of the individual applying the cast (P=0.21 and 0.86). Notably, there was a significantly higher incidence of cast injuries in individuals with a diagnosis of a neuromuscular disorder (37.4 per 1000) than those without (7.5 per 1000) (P<0.01). CONCLUSION: The incidence of cast injuries is 12.5 per 1000 children at our level I trauma tertiary referral pediatric clinic. Training level of the individual applying the cast or timing during the academic year did not correlate with cast injuries. Patients with neuromuscular disorders are at significantly higher risk for experiencing cast injuries. LEVEL OF EVIDENCE: Level III.

Caring for Children With Congenital Upper Extremity Differences.

The purpose of this article is to provide information about the changing landscapes in research, treatment, civil rights' protection, disability awareness, and accepted terminology in the care of children with congenital upper limb differences. This knowledge can guide clinical and nonclinical conversations between patients and their families.

Predicting Radial Head Instability in Multiple Hereditary Exostoses (MHE): A Multicenter Analysis of Risk Factors.

BACKGROUND: Forearm deformity occurs in one third of patients with multiple hereditary exostoses (MHE). Conservative and surgical treatment are aimed at preventing radial head subluxation and/or dislocation. Dislocation has been associated with isolated distal ulnar lesions, radial bowing, and ulnar shortening. Risk factors for radial head subluxation have not been clearly elucidated. This study aimed to identify risk factors for all radial head instability in MHE, to optimize early detection and prevent frank dislocation. METHODS: This multicenter retrospective case-control investigation included MHE patients with forearm lesions seen between 2000 and 2017 at 2 tertiary care children's hospitals. Demographic, clinical factors, radiographic measures, and surgical history were quantified. Comparisons were made between forearms that developed radial head instability versus those that remained stable and between those that progressed to radial head subluxation versus those that progressed to dislocation. RESULTS: This study included 171 forearms in 113 patients with MHE, who presented at a mean age of 8.0 years with a median follow-up time of 6.0 years. Nine forearms progressed to radial head subluxation (mean age: 10.2 y), and 24 forearms had radial head dislocation (mean age: 9.9 y). Five subluxations and 3 dislocations occurred despite preventative surgery. Initial radial bowing (7.2% vs. 8.5%, P=0.04), ulnar variance (-5.8% vs. 11.0%, P<0.001), and ulnar shortening (-2.5 vs. 9.1 mm, P=0.04) were predictive of radial head instability. Distal ulnar lesions and more severe ulnar variance (-5.8 vs. -10.6, P<0.001) and shortening (-2.5 vs. 13.2 mm, P=0.02) were associated with an increased risk of radial head subluxation. No significant differences were identified between forearms that progressed to subluxation versus those that progressed to dislocation. CONCLUSIONS: Distal ulnar lesions and radiographic measures can be used to determine the risk of radial head instability in MHE. Ulnar variance and shortening are early identifiable risk factors for radial head subluxation that can help guide monitoring and treatment. Radial bowing may be a late predictor of instability. LEVEL OF EVIDENCE: Level III-prognostic.

Prospective Evaluation of a Treatment Protocol Based on Fracture Displacement for Pediatric Lateral Condyle Humerus Fractures: A Preliminary Study.

BACKGROUND: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures. METHODS: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data. CONCLUSIONS: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making. LEVEL OF EVIDENCE: Level II.

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature.

BACKGROUND: In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. METHODS: Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. RESULTS: A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1-17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60-100%). Mean follow-up was 5.17 years (2-12 years). CONCLUSION: This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Upper extremity conversion disorder in children.

BACKGROUND: Conversion disorder in children presents a challenge to orthopedic surgeons. The condition is frequently associated with unnecessary diagnostic tests, treatments, and cost. The purpose of this study was to report a series of children with upper extremity conversion disorder to raise awareness for this uncommon condition and to assist with its diagnosis and management. METHODS: A retrospective review was conducted of 4 pediatric patients with upper extremity conversion disorder at a tertiary pediatric hospital from 2015 to 2017. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and cost of care. RESULTS: Patients presented with upper extremity muscle stiffness, unremitting dysmorphic muscle spasms, weakness, pain, very limited shoulder range of motion, and complaints of recurrent shoulder dislocations. All patients had been evaluated by multiple specialists and had an extensive prior diagnostic workup that was inconclusive. Two patients had a history of prior psychiatric illness and suicidal ideation, and all patients expressed despair and depression. All patients had normal physical examination findings under anesthesia. Two patients with muscle stiffness were treated with botulism injections and improved their shoulder range of motion. The average total charge for care since presentation was $42,729. CONCLUSIONS: Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. Examination under anesthesia is a successful diagnostic approach in children with suspected conversion disorder.

Outcomes of Isolated Radial Osteotomy for Volar Distal Radioulnar Joint Instability Following Radial Malunion in Children.

PURPOSE: The radius bone has a slight dorsoradial bow that allows for full forearm pronosupination around the ulna. However, radial malunion can lead to reversal of the radial bow and subsequent volar instability of the distal radioulnar joint (DRUJ), predominantly in supination. This study assessed the outcomes of corrective radial osteotomy for volar DRUJ instability after radial malunion in children. METHODS: The charts of 7 children (2 boys and 5 girls) treated with corrective radial osteotomy for volar DRUJ instability after a radius fracture or deformity were reviewed. Demographic, diagnostic, treatment, and complication information was collected for each patient. Radiographs at initial injury, fracture union, diagnosis of DRUJ instability, and final follow-up were reviewed for radiographic measurements of radial deformity and subsequent correction. RESULTS: Fractures included 4 distal radius, 2 proximal radius, and 1 plastic deformation of the radial shaft. Volar DRUJ instability was diagnosed an average of 2.7 years (range, 1-6 years) after fracture at an average age of 13.6 years (range, 12-17 years). Two of 7 patients had persistent symptoms despite having undergone previous soft tissue surgery for DRUJ instability. Radial osteotomy was performed on all patients (3 dorsal and 4 volar approaches), with an average sagittal plane correction of 23° ± 10° (range, 14° to 40°). Osteotomy site varied (3 proximal third, 1 middle third, and 3 distal third) based on the apex of maximal deformity. Patients were observed an average of 2.3 years (range, 1.0-5.7 years). At final follow-up, all patients had a stable DRUJ and no patient required soft tissue stabilization. CONCLUSIONS: Apex volar malunion of radial fractures may result in volar instability of the DRUJ. Radial osteotomy restored the normal apex dorsal radial bow and effectively stabilized the DRUJ without the need for soft tissue repair. Osteotomy should be tailored to the specific site of radiographic deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Clavicle Fracture Is Not Predictive of the Need for Microsurgery in Brachial Plexus Birth Palsy.

BACKGROUND: Brachial plexus birth palsy (BPBP) and clavicle fractures occur concurrently as well as in isolation during difficult deliveries. The concept that concurrent clavicle fracture may spare nerve injury has been advocated. Our aim was to compare those children with BPBP presenting to a tertiary care center with and without concurrent clavicle fractures and assess the utility of the presence of a clavicle fracture as a predictor of injury severity in children with BPBP. METHODS: Records of all patients belonging to a large prospective multicenter cohort study of infants with BPBP (Treatment and Outcomes of Brachial Plexus Injuries study) were analyzed for demographic information and birth information including risk factors, comorbidity, presence of clavicle fracture, and injury severity. RESULTS: The records of 639 children with BPBP were examined. Thirteen patients were excluded for incomplete data. Ninety-six children who sustained concurrent birth fracture and BPBP were identified (15%). Of these, 57 sustained clavicle fractures (9%), 44 sustained humerus fractures, and 4 sustained other fractures. Of the demographic factors analyzed, only the presence of gestational diabetes was found to be significantly higher in those children with fractures versus those without. The presence of a clavicle fracture did not change the rate of microsurgical intervention, nor did clavicle fracture rates differ by Toronto score, suggesting that there was no difference in injury severity between the 2 groups. CONCLUSIONS: In a large multicenter prospective study, 9% of children presenting with BPBP also sustained a clavicle fracture at birth. The presence of a clavicle fracture did not correlate with the severity of brachial plexus injury. We suggest that in study populations of children with severe enough BPBP to present to a tertiary care center, compared with studies collected in the obstetric population, the presence of a clavicle fracture is neither protective from nerve injury nor predictive of injury severity. LEVEL OF EVIDENCE: Level 2-prognostic.

Variability of the Anterior Humeral Line in Normal Pediatric Elbows.

BACKGROUND: The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows. METHODS: A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests. RESULTS: In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases. CONCLUSIONS: Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children. LEVEL OF EVIDENCE: Level III.

Long term functional outcomes after early childhood pollicization.

STUDY DESIGN: Retrospective Cohort INTRODUCTION: Important outcomes of polliciation to treat thumb hypoplasia/aplasia include strength, function, dexterity, and quality of life. PURPOSE OF THE STUDY: To evaluate outcomes and examine predictors of outcome after early childhood pollicization. METHODS: 8 children (10 hands) were evaluated 3-15 years after surgery. Physical examination, questionnaires, grip and pinch strength, Box and Blocks, 9-hole pegboard, and strength-dexterity (S-D) tests were performed. RESULTS: Pollicized hands had poor strength and performance on functional tests. Six of 10 pollicized hands had normal dexterity scores but less stability in maintaining a steady-state force. Predictors of poorer outcomes included older age at surgery, reduced metacarpophalangeal and interphalangeal range of motion, and radial absence. DISCUSSION: Pollicization resulted in poor strength and overall function, but normal dexterity was often achieved using altered control strategies. CONCLUSIONS: Most children should obtain adequate dexterity despite weakness after pollicization except older or severely involved children. LEVEL OF EVIDENCE: IV.

Assessing shoulder motion in children: age limitations to Mallet and ABC Loops.

BACKGROUND: Shoulder ROM and function of the shoulder are difficult to evaluate in young children. There has been no determination of the age at which children can comply with the current assessment tools in use, but doing so would be important, because it gives us more accurate insight into the development and assessment of shoulder functional ROM in young children. QUESTIONS/PURPOSES: We (1) determined whether age would limit the use of two different observational scales used to assess shoulder ROM and function in young children (the Mallet scale and the ABC Loops protocol); and (2) compared the two scales in terms of intra- and interobserver reliabilities. METHODS: Sixty-five able-bodied children (32 boys, 33 girls; mean age, 3.9 years; range, 0.5-7.0 years) were recruited from local preschools and evaluated using the Mallet scale and ABC Loops protocol. Children were assessed on their ability to complete the examinations and time to completion for each measurement protocol. Intra- and interobserver reliability was tested by percentage agreement. Forty-eight children (mean age, 4.4 years; SD, 1.3 years) were able to complete the Mallet and ABC Loops measurement protocols; 17 children (mean age, 2.3 years; SD, 1.1 years) failed to complete either test. RESULTS: Younger children had more difficulty completing the examinations; there was a strong negative correlation between age and failure: probability of failure increased with decreasing age (Pearson r = -0.601, p < 0.001). Children who were able to complete one test were able to complete the other. Interobserver and intraobserver agreement was very high for both scales (in excess of 95% for all comparisons), and with the numbers available, there were no differences between the scales. CONCLUSIONS: The Mallet scale and ABC Loops protocol have high reliability metrics in children younger than 6 years, but very young children (those younger than 3 years) generally will not be able to complete the examinations. The ABC Loops test took longer to perform than the Mallet scale but may more comprehensively evaluate a child's functional capabilities. We therefore state that both assessment tools can be reliably used in children older than 3 years; we believe the ABC Loops gives a more accurate assessment of shoulder ROM.

Delayed reconstruction of a flexor digitorum profundus tendon lacerated during cesarean delivery: case report.

We present a case of primary tendon grafting in a 14-month-old infant for an index finger flexor digitorum profundus tendon laceration sustained during cesarean section with excellent functional results at 2-year follow-up.

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

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, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. METHODS: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. RESULTS: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). CONCLUSIONS: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. LEVEL OF EVIDENCE: Level I prognostic study.

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

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. However, the RCL has not been rigorously defined or validated in young children. METHODS: The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables. RESULTS: Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants. CONCLUSIONS: The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury. LEVEL OF EVIDENCE: Diagnostic Level 3.

Development of a Group Curriculum for Children With Congenital Upper Limb Difference (CULD) and Their Caregivers.

Caring for patients with congenital upper limb differences (CULD) requires an understanding of unique psychosocial challenges. The study purpose was to describe the needs of children with CULD and their caregivers to develop a group curriculum. This mixed-method study included 13 mothers and one father of children with CULD (age 3 months to 14 years; mean 7.2 ± 4.3 years) using Patient-Reported Outcomes Measurement Information System Parent Proxy Reports and caregiver interviews. Patient-Reported Outcomes Measurement Information System Peer Relationships (M = 48.1 ± 10.9) and Pain Interference (M = 44.5 ± 7.5) T-scores were average with below average scores for Physical Function: Upper Extremity (M = 31.9 ± 12.1). Caregivers expressed high interest in groups to create community and mutual support covering themes of responding to questions from strangers, social and coping skills, building self-confidence, accessing resources, advocacy skills, and advice from adults with CULD. Access to a support group with a curriculum addressing CULD-related patient and family needs may improve care.

Dedicated Early Morning Orthopaedic Trauma Operating Room Is Associated With Shorter Time to Surgery and Decreased Length of Hospital Stay for Children Undergoing Surgical Treatment of Supracondylar Humerus Fractures: A Retrospective Cohort Study.

INTRODUCTION: The purpose of this study was to investigate whether the use of a dedicated early morning orthopaedic trauma operating room (OR) resulted in shorter wait times, decreased surgical times, decreased length of stay (LOS), and decreased complications in children treated with urgent surgical intervention for supracondylar humerus fractures. METHODS: This retrospective comparative cohort study at a level I pediatric trauma center included patients younger than 12 years with supracondylar humerus fractures urgently treated with closed or open reduction and percutaneous pinning. Index surgical cases from April 28, 2013, to February 26, 2020, were included. Patients with prior humerus fracture, concomitant injuries, open fracture, pulseless supracondylar fracture, or missing data were excluded. Patients were analyzed based on the type of OR: dedicated early morning orthopaedic trauma OR or typical daytime orthopaedic OR. The primary outcome was time from presentation to surgery. Secondary outcomes included surgical time, complications, and LOS. RESULTS: A total of 401 patients with a mean age of 5 ± 2 (range: 1 to 11) years and a mean follow-up of 2.0 ± 2.1 (range: 0.5 to 25.0) months were included, of whom 137 patients (34%) underwent surgery in the early morning dedicated orthopaedic trauma OR. The dedicated early morning orthopaedic OR group had significantly less time from presentation to surgery (7.5 versus 9.4 hours; P = 0.0002) and shorter LOS (21.0 versus 24.0 hours; P = 0.004) compared with children treated in the typical daytime orthopaedic OR. Surgical time (31.1 versus 32.6 minutes; P = 0.40) and complication rates (5.8% versus 4.9%; P = 0.65) were similar between the groups. No revision surgery was required in either group. DISCUSSION: Surgical wait times were diminished with use of the dedicated early morning OR, as was LOS. Surgical times and complication rates were similar between groups. Institutions may consider adopting a dedicated early morning orthopaedic trauma OR to improve surgical wait times and decrease LOS. LEVEL OF EVIDENCE: III.

Pediatric trigger thumb caused by a flexor tendon sheath ganglion.

Pediatric trigger thumb is a common reason for toddlers to present to a pediatric orthopaedic surgeon. There is controversy over the precise etiology and optimal treatment method. Current accepted diagnostic and treatment algorithms in children have not varied based on etiology. This report describes the clinical presentation and care of a 3-year-old child with pediatric trigger thumb and surgical findings of a large flexor tendon sheath ganglion at the level of the annular pulley with no apparent nodule within the FPL. The potential implications for consideration of etiology in current diagnostic and treatment guidelines are discussed.