Abbreviated Outpatient Upper Extremity Fracture Care to Avoid Clinic and Hospital Environmental Encounters During the COVID-19 Pandemic: A New Approach to Fracture Care?

BACKGROUND: To minimize in-person visits during the COVID-19 pandemic, a new fracture care protocol for children with complete and stable, nondisplaced or minimally displaced upper extremity (UE) fractures has been implemented. This protocol involves immobilization with a bivalved cast, which allows for home cast removal during a telemedicine visit, and no follow-up radiographs, thus eliminating the requirement for a return to clinic. The purpose of this study is to evaluate the outcomes and parent satisfaction of this new abbreviated fracture care protocol. METHODS: Between May 2020 and April 2021, during the COVID-19 pandemic, children with complete and stable, nondisplaced or minimally displaced UE fractures were treated with a bivalved cast and 1 follow-up telemedicine visit for home cast removal. A prospective longitudinal study of these patients was performed. The PROMIS Upper Extremity questionnaire was administered at enrollment and 3 months follow-up. Parents completed a satisfaction survey after home cast removal. Demographic data and information regarding complications were collected. A historical cohort of controls treated with standard cast in 2019 was used for comparison. RESULTS: A total of 56 patients with a mean age of 8±3 years (range 2 to 15) were prospectively enrolled in this study. Parent-reported PROMIS Upper Extremity scores showed a significant increase from 24.9 (95% confidence interval=20.8-29.1) at enrollment to 51.6 (95% confidence interval=50.8-52.5) at 3 months follow-up (P<0.001). Results of the satisfaction survey (n=39) showed all parents were either very satisfied (85%) or satisfied (15%). In addition, 10% of parents would have initially preferred to come into clinic for cast removal and 90% of parents would prefer this new treatment plan in the future. Patients in the abbreviated care cohort returned to clinic for a median 1 in-person visits, compared with 2 for historical controls (n=183, P<0.001). Abbreviated care patients received fewer (1.0) radiographs than controls (2.0, P<0.001). Complication rate did not differ between the groups (P=0.77). CONCLUSIONS: Complete and stable, nonminimally or minimally displaced UE fractures can be cared for safely and effectively in a single in-person visit, with a telemedicine cast removal visit. Parents are satisfied with this abbreviated protocol and prefer it to additional in-person visits. LEVEL OF EVIDENCE: Level III.

Observation Versus Cast Treatment of Toddler's Fractures.

BACKGROUND: Nondisplaced metaphyseal fractures of the distal tibia, or toddler's fractures, are one of the most common pediatric injuries. Healing typically occurs quickly without sequelae. Treatment ranges from long leg cast immobilization to observation. This study compares short-term clinical and radiographic outcomes of toddler's fractures treated with long leg casting versus observation. METHODS: Patients with toddler's fractures were offered enrollment and randomization at diagnosis. Because many families opposed randomization, a preference arm was added after one year. All subjects were analyzed as a prospective cohort. Radiographs were obtained at diagnosis and 4 weeks. A modified Oxford Ankle Foot Questionnaire for Children (OAFQ-C) and family satisfaction survey were collected at diagnosis, 4 and 8 weeks. Scores were analyzed using mixed effect models. Family satisfaction surveys were compared using a Wilcoxon rank sum test. RESULTS: Forty-four subjects participated in the study, 34 (77%) in the preference arm and 10 (23%) in the randomized cohort. The median patient age was comparable between the cast and the observation groups, 2.0 versus 1.8 years, respectively. Significant improvement in OAFQ-C scores was observed in both groups over 8 weeks (P<0.01). Patients in the observation group had a higher initial play score than the cast group (P=0.03). The observation group trended toward higher physical scores at all time points (P=0.11). There was no significant difference in emotional scores between groups (P=0.77). No displacement was observed in any patient. Casted patients had significantly more minor complications with 4 patients requiring cast change or removal compared with 0 in the observed group (P=0.01). At 8 weeks, 80% of parents in the cast group were likely or very likely to choose the same treatment compared with 95.6% in the observation group. Family satisfaction scores did not differ between groups (P=0.18). They demonstrated differences in perceived normal walking at 4 weeks, with 50% of casted patients walking normally compared with 92% of observed patients. Over 90% of patients in both groups were reportedly walking normally at week 8. CONCLUSION: Observation of toddler's fractures results in equivalent clinical and radiographic outcomes, high family satisfaction and fewer complications compared with treatment with a long leg cast. LEVEL OF EVIDENCE: Level II.

Diagnostic Criteria for the Painful Swollen Pediatric Knee: Distinguishing Septic Arthritis From Aseptic Effusion in a Non-Lyme Endemic Area.

Purpose: The child with a painful swollen knee must be worked-up for possible septic arthritis; the classic clinical prediction algorithms for septic arthritis of the hip may not be the best models to apply to the knee. Materials and methods: This was a retrospective case-control study of 17 years of children presenting to one hospital with a chief complaint of a painful swollen knee, to evaluate the appropriateness of applying a previously described clinical practice algorithm for the hip in differentiating between the septic and aseptic causes of the painful knee effusions. The diagnoses of true septic arthritis, presumed septic arthritis, and aseptic effusion were established, based upon the cultures of synovial fluid, blood cultures, synovial cell counts, and clinical course. Using a logistic regression model, the disease status was regressed on both the demographic and clinical variables. Results: In the study, 122 patients were included: 51 with true septic arthritis, 37 with presumed septic arthritis, and 34 with aseptic knee effusion. After applying a backward elimination, age <5 years and C-reactive protein (CRP) >2.0 mg/dl remained in the model, and predicted probabilities of having septic knee arthritis ranged from 15% for the lowest risk to 95% for the highest risk. Adding a knee aspiration including percent polymorphonucleocytes (%PMN) substantially improved the overall model performance, lowering the lowest risk to 11% while raising the highest risk to 96%. Conclusions: This predictive model suggests that the likelihood of pediatric septic arthritis of the knee is >90% when both "age <5 years" and "CRP > 2.0 mg/dl" are present in a child with a painful swollen knee, though, in the absence of these factors, the risk of septic arthritis remains over 15%. Aspiration of the knee for those patients would be the best next step.

Association Between 45° Flexion Anteroposterior Elbow Radiographs and Diagnostic Accuracy of Capitellum Osteochondritis Dissecans.

BACKGROUND: An anteroposterior (AP) radiograph of the elbow in 45° of flexion has been suggested to increase the diagnostic accuracy of capitellum osteochondritis dissecans (OCD). PURPOSE: To assess the diagnostic performance, inter- and intraobserver reliability, and confidence level for identifying capitellum OCD using plain radiographs (AP, lateral, and 45° flexion AP). STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: This was a retrospective study of pediatric and adolescent patients with capitellum OCD and a control group. Six independent clinicians who were blinded to the official radiologists' reports reviewed images on 2 separate occasions, 1 week apart. A 5-point Likert scale was used to assess the clinicians' level of confidence. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for individual and combinations of radiographic views. Inter- and intraobserver reliability was determined using Cohen kappa (κ) coefficients. RESULTS: A total of 28 elbows (mean age, 12.5 ± 2 years) were included. There were no differences in age (P = .18), sex (P = .62), or laterality (P > .999) between groups. There were marked variations in the diagnostic accuracy between views: sensitivity (AP, 85.1; lateral, 73.2; 45° flexion AP, 91.7), specificity (AP, 89.3; lateral, 91.7; 45° flexion AP, 91.1), PPV (AP, 88.8; lateral, 89.8; 45° flexion AP, 91.1), NPV (AP, 85.7; lateral, 77.4; 45° flexion AP, 91.6), and accuracy (AP, 87.2; lateral, 82.4; 45° flexion AP, 91.4). Standard radiographs (AP and lateral views) failed to diagnose capitellum OCD in 4.8% of cases. The sensitivity of the 3 combined views was 100%. Confidence intervals in the clinicians' diagnostic assessments were similar for each view (AP, 4.0; lateral, 4.0; and 45° flexion AP, 4.1). Interobserver reliability was substantial for AP and lateral views (κ = 0.65 and κ = 0.60, respectively) but highest for the 45° flexion AP radiographs (κ = 0.72). Intraobserver reliability for the 45° flexion AP view was moderate to almost perfect (κ = 0.45 to 0.93). CONCLUSION: The 45° flexion AP view can detect capitellum OCD with excellent accuracy, a high level of confidence, and substantial interobserver agreement. When added to standard AP and lateral radiographs, the 45° flexion AP view aids in the identification of capitellum OCD.

Prevalence and Severity of Juvenile Osteochondritis Dissecans in Patients With Juvenile Idiopathic Arthritis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic arthritides presenting in patients aged ≤16 years, with a prevalence of 16 to 150 per 100,000. Juvenile osteochondritis dissecans (OCD) is an idiopathic disease of articular cartilage and subchondral bone, has an onset age of 10 to 16 years, and often affects the knee, with a prevalence of 2 to 18 per 100,000. Currently, there are few studies that have evaluated the relationship between JIA and OCD. HYPOTHESIS: OCD is more prevalent in children with JIA, and when diagnosed in such patients, OCD often presents at an advanced state. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The medical records of patients with diagnoses of both JIA and OCD treated between January 2008 and March 2019 at a single children's hospital were retrospectively reviewed. Associations between timing of diagnoses, number and types of corticosteroid treatments, category of arthritis, timing of diagnoses, and lesion stability were examined with Spearman correlation coefficients. RESULTS: A total of 2021 patients with JIA were identified, 20 of whom (19 female, 1 male) had OCD of the knee and/or talus for a prevalence of 1 in 100 or 1000 in 100,000, or approximately 50 to 500 times that of the general population. These 20 patients had a total of 28 OCD lesions: 43% (9 femur, 3 talus) were radiographically stable over time, 50% (10 femur, 2 patella, 2 talus) were unstable at initial diagnosis, and 7% (2 femur) were initially stable but progressed to unstable lesions despite drilling. Twelve patients (60%) underwent surgery: 4 (20%) with stable femoral lesions for persistent symptoms despite prolonged nonoperative treatment and 8 (40%) for treatment of their unstable lesions (femoral and patellar). Within our study design, we could identify no significant associations between lesion stability and timing of diagnoses, number of joint injections, or limb deformities, nor were there associations between timing of JIA and OCD diagnoses and category of arthritis. CONCLUSION: In our population of patients with JIA, OCD lesions were found to be 50 to 500 times more prevalent when compared with published rates in the general population and often presented at an advanced state, with instability or delayed healing requiring surgery for stabilization or resolution of symptoms.

Low Preoperative Lung Functions in Children With Early Onset Scoliosis Predict Postoperative Length of Stay.

INTRODUCTION: Children with early onset scoliosis (EOS) undergoing spine surgery often have significant respiratory disease. Preoperative risk assessments that predict an increased length of hospital stay (LOS) for this group have not been previously evaluated. METHODS: A voluntary protocol using preoperative lung function studies began among participants of a multicenter registry in 2016. Preoperative assessments were standardized to include spirometry, blood hemoglobin levels, serum bicarbonate, albumin and prealbumin; radiographic parameters of the spine, C-EOS classification and need for preoperative pulmonary assistance before initial growth friendly device insertion or "definitive" spine fusion. Primary outcome was LOS postoperatively. Data, including age, diagnosis, and type of surgery, was collected prospectively. Secondary outcomes measured included intensive care unit LOS, requirement for new pulmonary assistance on discharge, and pulmonary complications. Groups were compared using the Fisher exact tests. RESULTS: Of 525 children enrolled, 101 (20%) had preoperative spirometry. Median age was 8.9 years [interquartile range (IQR): 4.27]. Etiologies for EOS included 29 neuromuscular (28%), 33 idiopathic (32%), 19 syndromic (19%), and 22 congenital (21%) scoliosis. Eighty (78%) had growing rod (GR) insertions; 23 (22%) had spine fusion SF. Eighteen subjects (17%) were hospitalized ≥7 days (median=9 d); 83 had a LOS <7 days (median=3 d). Percentage of forced vital capacity (FVC%) predicted was inversely associated with LOS ≥7 days with a median of 75.3% (IQR: 41.7) for LOS <7 days and 51.7% (IQR: 41.6) (P=0.02). There were no detectable differences in LOS for other preoperative values. CONCLUSION: FVC predicted ≤50% preoperatively in children undergoing initial growth friendly rod insertion or definitive fusion after growth friendly treatment is associated with an increased risk of postoperative hospital stays ≥7 days. As demonstrated in previous studies, severe restrictive lung disease (FVC% predicted at or below 50%) is associated with increased risk of poorer outcomes for EOS patients.

Best practice guidelines in managing the craniofacial aspects of skeletal dysplasia.

BACKGROUND: Recognition and appropriate management of the craniofacial manifestations of patients with skeletal dysplasia are challenging, due to the rarity of these conditions, and dearth of literature to support evidence-based clinical decision making. METHODS: Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, best practice guidelines in the management of craniofacial aspects of these patients. RESULTS: After a comprehensive literature review, 23 initial statements were generated and critically discussed, with subsequent development of a list of 22 best practice guidelines after a second round voting. CONCLUSIONS: The guidelines are presented and discussed to provide context and assistance for clinicians in their decision making in this important and challenging component of care for patients with skeletal dysplasia, in order standardize care and improve outcomes.

Seasonal Variation in Parental Satisfaction With Pediatric Orthopaedics.

BACKGROUND: The degree of parental satisfaction with health care is determined by the family's characteristics and expectations. Many aspects of human physiology and behavior have seasonal rhythms. The purpose of the present study was to determine whether parental satisfaction scores vary across the year in a pediatric orthopaedic outpatient population. METHODS: We retrospectively reviewed a total of 22,951 parental satisfaction scores related to outpatient pediatric orthopaedic encounters between October 2015 and April 2019. Parental satisfaction was measured using the provider subdomain of the shortened version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Families were stratified according to various pediatric orthopaedic subspecialty services. RESULTS: The satisfaction scores of all pediatric orthopaedic encounters combined did not vary significantly across the year (P=0.8745). When the families were stratified into groups by pediatric orthopaedic subspecialty clinic, variation in seasons was not associated with statistically significant variation in satisfaction scores for the elective surgery, sports medicine, trauma/fracture care, and hand/upper extremity services. However, satisfaction with the spine service was significantly lower in the winter compared with the summer and fall (73.9±3.8 vs. 83.5±5.3 and 82.6±3.6, respectively; P=0.0147). CONCLUSIONS: The provision of pediatric spine care in a region with 4 distinct seasons received lower parental satisfaction scores during the winter than during the summer and fall. This seasonal variation is an additional source of bias in the measurement of satisfaction with health care. LEVEL OF EVIDENCE: Level II-retrospective study.

Classifying vertebral artery anatomy abnormality in children with skeletal dysplasia.

PURPOSE: Skeletal dysplasia (SKD) have predictably abnormal occipitocervical skeletal anatomy, but a similar understanding of their vertebral artery anatomy is not known. Knowledge and classification of vertebral artery anatomy in SKD patients is important for safe surgical planning. We aimed to determine if predictably abnormal vertebral artery anatomy exists in pediatric SKD. METHODS: We performed a retrospective review of CTAs of the neck for pediatric patients at a single institution from 2006 to 2018. CTAs in SKD and controls were reviewed independently in blinded fashion by two radiologists who classified dominance, vessel curvature at C2, direction at C3, and presence of fenestration and intersegmental artery. RESULTS: 14 skeletal dysplasia patients were compared to 32 controls. The path of the vertebral artery at C2 foramen was no different between the cohorts or by side, right (p = 0.43) or left (p = 0.13), nor for medial or lateral exiting direction from C3 foramen on right (p = 0.82) or left (p = 0.60). Dominance was most commonly neutral in both groups (71% in SKD and 63% in controls). There were no fenestrated nor first intersegmental arteries in our cohort. CONCLUSION: No systematic differences were detected between SKD and control patients with respect to vertebral artery anatomy. Nonetheless, surgically relevant variability was observed in both groups. Paying particular attention to the direction of exit at C3 and curvature at C2 with respect to the foramen and vessel dominance are important and easily classifiable abnormalities that both surgeons and radiologists can use to communicate and employ in pre-operative planning. LEVEL OF EVIDENCE: III.

Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines.

INTRODUCTION: The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital. METHODS: Retrospective and prospective data were collected from 2 years before and 5 years after checklist implementation. This included the patient safety checklists from August 2011 through August 2016. Patients aged 0 to 18 years with a diaphyseal femur fracture were queried from the EMR and included in this study. Patient charts were reviewed for complications, including nerve injury, pressure sore, leg length discrepancy, loss of reduction, failure of fixation, nonunion, delayed union, and infection. Compliance rates were reported based on the AAOS clinical practice guidelines. RESULTS: A total of 313 patients for the postchecklist period were reviewed in this study. Of 219 patients eligible for inclusion, 198 had checklists completed (group B). This group was compared with 100 patients with diaphyseal femur fractures from the period before implementation of the checklist (group A). We found no statistical difference in the number of patients with complications between groups (12% in both groups, P = 0.988). Postoperative checklists demonstrated that 89.9% of patients (178/198) received age-appropriate treatment consistent with the AAOS guideline recommendations after implementation of the checklist. Before the checklist implementation (group A), 94% (94/100) adhered to the guidelines. CONCLUSION: This study reveals high compliance rates with the AAOS evidence-based clinical practice guideline for the management of pediatric femur fractures. Implementing standardized checklists is possible by embedding them into the EMR. Implementation of checklists did not improve compliance or patient outcomes.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Best practice guidelines for management of spinal disorders in skeletal dysplasia.

BACKGROUND: Disorders of the spine present a common and difficult management concern in patients with skeletal dysplasia. Due to the rarity of these conditions however, the literature, largely consisting of small, single institution case series, is sparse in regard to well-designed studies to support clinical decision making in these situations. METHODS: Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, "best practice" guidelines in the care of spinal disorders in patients with skeletal dysplasia. RESULTS: Starting with 33 statements, the group a developed a list of 31 "best practice" guidelines. CONCLUSIONS: The guidelines are presented and discussed to provide context for clinicians in their decision making in this often-challenging realm of care.

Comparison of Continuous Adductor Canal and Femoral Nerve Blocks for Analgesia and Return of Quadriceps Function After Anterior Cruciate Ligament Reconstruction in Adolescent Patients.

PURPOSE: To compare early pain relief and late quadriceps function after anterior cruciate ligament reconstruction (ACLR) with hamstring autograft in adolescent patients treated with either a continuous femoral nerve block (cFNB) or continuous adductor canal block (cACB). METHODS: We retrospectively reviewed a consecutive series of adolescent patients who underwent ACLR and received either a cACB or cFNB for postoperative pain management. Over a 1-year period, all patients underwent ACLR with cFNBs. Over the subsequent 9 months, all patients underwent their ACLR with cACBs. Patient demographics, postoperative pain scores, opioid consumption, satisfaction and complications, and dates and results of quadriceps function derived at the Return to Sports evaluation were compared. RESULTS: Ninety-one patients (53 cFNB, 38 cACB) were reviewed. There were no differences in the demographics of the 2 groups. There were no statistically significant differences between groups in variations in postoperative pain scores (P = .21), or satisfaction with the blocks (P = .93). Patients in the cFNB group consumed a greater number of opioid doses on postoperative day 3 (2.2 ± 2.1 doses cFNB, 1.1 ± 1.6 doses cACB, P = .03) and a greater number of opioid doses overall for postoperative days 1 to 3 (mean 6.8 ± 5.3 doses cFNB, 3.8 ± 2.1 doses cACB, P = .03). There was no difference in time to return of acceptable quadriceps strength and function when comparing the 2 groups (30.9 ± 7.7 weeks cFNB, 28.9 ± 6.6 weeks cACB, P = .087). CONCLUSIONS: We found few differences in postoperative analgesic requirements when comparing patients who underwent ACLR with hamstring autograft with a cACB to those who underwent a similar procedure with a cFNB. Return of quadriceps strength and function by six months did not appear to vary with regional technique, either cACB or cFNB, employed at surgery. LEVEL OF EVIDENCE: III, Retrospective comparative study.

Prospective spine at risk program for prevalence of intracanal spine lesions in pediatric hereditary multiple osteochondromas.

STUDY DESIGN: Retrospective cohort study OBJECTIVES: To determine prevalence of hereditary multiple osteochondromas (HMO) and utility of MRI surveillance in a prospective Spine at Risk (SAR) program. Unidentified intraspinal exostoses in HMO can lead to neurologic injury in children during sedated procedures but no MRI guidelines exist. We sought to determine the prevalence and age of intraspinal exostoses from MRIs, and indications for MRI surveillance. METHODS: Retrospective review was performed of pediatric HMO patients who underwent total spine MRIs at a single institution after a prospective SAR program was instituted. Charts were reviewed for MRI indication and findings, symptoms, surgery, and location of other exostoses. Fisher's exact test was used to compare categorical variables and T test to compare continuous variables. Predictive value of pelvic/rib exostoses was calculated for intraspinal lesions. RESULTS: Forty-three patients with HMO underwent total spine MRIs with average age of 11.5 years. Fifteen (35%) patients had exostoses on vertebral column, eight (19%) had intra-canal spinal exostoses. Higher prevalence of spine lesions occurred in symptomatic patients than asymptomatic (any spinal lesion: 73% prevalence in symptomatic vs 22% in asymptomatic, p < 0.005; intra-canal spinal lesion: 46% vs 9%, p < 0.05). Only two of the 11 'symptomatic presentations' could be attributable to intracanal spinal exostoses. Only one intra-canal exostosis found on asymptomatic surveillance was treated surgically. Presence of pelvic or rib exostoses were not strongly predictive of intra-canal lesions (23% PPV, 85% NPV, 63% sensitivity, 51% specificity). CONCLUSIONS: Even with the presence of intra-canal exostoses, true symptomatic lesions are rare. Rib and pelvic lesions were not predictive of intra-canal lesions in our population. We recommend obtaining MRIs at time of preoperative evaluation in asymptomatic children old enough to not need sedation, or in patients with true neurologic symptoms to prevent unnecessary sedation of younger children for surveillance MRI. LEVEL OF EVIDENCE: III.

Persistence and Progression of Airway Obstruction in Children With Early Onset Scoliosis.

BACKGROUND: Obstructive lung disease occurs in 30% of children with early onset scoliosis (EOS); changes in degree of airway obstruction over time have not been reported. METHODS: Longitudinal patterns of incidental, persistent, and progressive airway obstruction were retrospectively analyzed in a cohort of children with EOS with at least 1 forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) value <85% on serial spirometric assessments over a ≥3-year observation period. The prevalence of clinical features and the severity of coronal and sagittal spine deformities for each group at the beginning and end of the study period were compared. RESULTS: Airway obstruction was incidental in 12 (24%) and persistent in 37 (76%) of 49 children with EOS. Twenty of 37 (54%) of those with persistent obstruction developed progressive airway obstruction. The decline in FEV1/FVC over 6±2 years was insignificant in the incidental group (4%±2%) and the persistent nonprogressive group (7%±4%) but significant in the progressive group (13%±4%, t test; P=0.002). In total, 29% of the 49 children at the onset and 57% at the end of the study had airway obstruction. The incidental, persistent nonprogressive, and progressive groups did not differ with regard to age, diagnosis distribution, or sex. The initial coronal curve size, apex, direction of the curve, and degree of kyphosis were statistically similar among the 3 groups. Coronal curve magnitude inversely correlated with FEV1/FVC at the end but not the beginning of the study (r=-0.19, P=0.002). Six of 19 responded to bronchodilator treatment, suggesting concurrent asthma. Airway obstruction did not relate to restrictive pulmonary abnormalities measured by FVC at first or last timepoints [slope=-0.076 (95% confidence interval, -0.99 to 0.038; P=0.19)]. Changes in degrees of airway obstruction and restrictive lung disease over time did not correlate [slope=-0.125 (95% confidence interval, -0.294 to 0.044; P=0.14)]. CONCLUSIONS: Children with EOS and progressive airway obstruction represent an important subgroup which may require new surgical and nonsurgical treatment strategies to prevent loss of lung function over time.

Outcome Tools in Pediatric Foot and Ankle Patients: Comparing Child and Parent Scores.

INTRODUCTION: The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is validated for assessing the impact of foot and ankle conditions in pediatric patients. The purpose of this cross-sectional study is to assess child-parent concordance and identify patient factors that predict improved agreement. METHODS: Patients aged 8 to 16 years with foot and ankle conditions and their parents completed the OxAFQ-C during routine clinic visits over a 9-month period. Demographic and medical information was collected by chart reviews. Responses in each domain were compared using a Wilcoxon signed-rank test, and the comparisons of responses by sex were analyzed with Wilcoxon rank-sum tests. Concordance was assessed with intraclass correlation coefficients. RESULTS: There were 87 child-parent dyads with 50 female patients (57.5%) and 37 male patients (42.5%). Most parent responders were mothers (84%). The mean patient age was 12.4 (±2.2) years. The most common diagnosis was pes planus (17%). Child scores were significantly higher than their parents' in the school and play (P = 0.008) and emotional (P = 0.001) domains. When stratified by age, children younger than 13 years had significantly higher scores than their parents across all domains (P = 0.015 physical, 0.002 school and play, 0.001 emotional), although the concordance for the school and play and emotional domains was only moderate (0.73 and 0.58, respectively). Female patients and their parents reported significantly lower scores compared with their male counterparts only in the emotional domain (84.37 vs 93.75, P = 0.025). CONCLUSION: Concordance is good between child and parent scores of the OxAFQ-C for assessing the impact of foot and ankle conditions. When stratified by age, patients younger than 13 years of age had higher scores than their parents' in all domains with the lowest concordance for the school and play and emotional domains. Female patients and their parents reported significantly lower scores than their male counterparts in the emotional domain. LEVEL OF EVIDENCE: Level IV.

The Utility of the Early Postoperative Follow-up and Radiographs After Operative Treatment of Supracondylar Humerus Fractures in Children.

BACKGROUND: Supracondylar humerus (SCH) fractures are common elbow injuries in pediatric patients. The American Academy of Orthopedic Surgeons published guidelines for the standard of care in the treatment of displaced SCH fractures, however, no recommendations for follow-up care were made. With the recent push to eliminate unnecessary radiographs and decrease health care costs, many are questioning postoperative protocols. The purpose of our study was to evaluate the utility of the 1-week follow-up appointment after closed reduction and percutaneous pinning (CRPP) of displaced SCH fractures. METHODS: A retrospective review performed at a single institution from 2014 to 2016 included patients under 14 years of age with a closed, displaced SCH fracture treated with CRPP. Exclusion criteria included patients without complete clinical or radiographic follow-up. Variables examined included time to initial follow-up, change in treatment plan after 1-week x-rays, complications, demographics, fracture type, pin number and configuration, reduction parameters, immobilization, time to pin removal, duration of casting, and clinical outcome. RESULTS: A total of 412 patients were divided into 2 groups based on time to initial follow-up. Overall, 368 had an initial follow-up at 7 to 10 days (group 1) and 44 at 21 to 28 days (group 2). There was no difference in age, sex, fracture type, pin configuration, or a number of pins between groups. Statistically significant findings included time to initial follow-up and days to pin removal (group 1 at 26.2 d vs. group 2 at 23.8 d), type of immobilization (group 1 with 5% circumferential casts and group 2 with 70%), and time to surgery (26.2 vs. 62.9 h, respectively). There was no significant difference in complication rates and only a 0.5% rate of change in management in group 1. CONCLUSIONS: Early postoperative follow-up and radiographs did not change the patient outcome and might be eliminated in children with displaced SCH fractures treated with CRPP. Given the current focus of on efficiency and cost-effective care, eliminating the 1-week postoperative appointment would improve appointment availability and decrease medical cost. LEVEL OF EVIDENCE: Level III-Therapeutic.

C-Reactive Protein Level at Time of Discharge Is Not Predictive of Risk of Reoperation or Readmission in Children With Septic Arthritis.

Purpose: C-reactive protein (CRP) level is used at our tertiary pediatric hospital in the diagnosis, management, and discharge evaluation of patients with septic arthritis. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP < 2.0 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure. Methods: Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were identified with ICD 9/10 and related CPT codes. Systematic chart reviews were performed to obtain demographic data, infection characteristics, and treatment details. Bivariate tests of associations between potential risk factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests. Results: One hundred and eighty-three children with septic arthritis were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including six who required reoperation. Mean CRP at discharge for single-admission patients was 1.71 mg/dL (± 1.07) and 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664). Forty-eight children (25.9%) had CRP values greater than the recommended 2.0 mg/dL at discharge. Only three of these patients (6.2%) were later readmitted. The only common variable of the readmitted children was an antibiotic-resistant or atypical causative bacteria. Conclusions: CRP levels are useful in monitoring treatment efficacy of septic arthritis in children but are not reliable as a discharge criterion to prevent readmission or reoperation. We recommend determining discharge readiness on the basis of clinical improvement and down-trending CRP values. There was a higher risk of readmission in children with an antibiotic-resistant or atypical causative bacteria. Close monitoring of these patients and those with negative cultures at time of discharge is suggested to identify signs of persistent infection. Level of evidence: III, retrospective cohort study.

An Updated Algorithm for Radiographic Screening of Upper Cervical Instability in Patients With Down Syndrome.

STUDY DESIGN: Retrospective evaluation of cervical spine images from 2006-2012 for the purposes of "screening" children with Down syndrome for instability. OBJECTIVE: To determine whether a full series of cervical spine images including flexion/extension lateral (FEL) radiographs was needed to avoid missing upper cervical instability. SUMMARY OF BACKGROUND DATA: The best algorithm, measurements, and criteria for screening children with Down syndrome for upper cervical instability are controversial. Many authors have recommended obtaining flexion and extension views. We noted that patients who require surgical stabilization due to myelopathy or cord compression typically have grossly abnormal radiographic measurements on the neutral upright lateral (NUL) cervical spine radiograph. METHODS: The atlanto-dental interval, space available for cord, and basion axial interval were measured on all films. The Weisel-Rothman measurement was made in the FEL series. Clinical outcome of those with abnormal measurements were reviewed. Sensitivity, specificity, and positive and negative predictive values of NUL and FEL radiographs for identifying clinically significant cervical spine instability were calculated. RESULTS: A total of 240 cervical spine series in 213 patients with Down syndrome between the ages of 4 months and 25 years were reviewed. One hundred seventy-two children had an NUL view, and 88 of these patients also had FEL views. Only one of 88 patients was found to have an abnormal atlanto-dental interval (≥6 mm), space available for cord at C1 (≤14 mm), or basion axial interval (>12 mm) on an FEL series that did not have an abnormal measurement on the NUL radiograph. This patient had no evidence of cord compression or myelopathy. CONCLUSIONS: Obtaining a single NUL radiograph is an efficient method for radiographic screening of cervical spine instability. Further evaluation may be required if abnormal measurements are identified on the NUL radiograph. We also propose new "normal" values for the common radiographic measurements used in assessing risk of cervical spine instability in patients with Down syndrome. LEVEL OF EVIDENCE: Level IV.

Use of diffusion tension imaging in the evaluation of pediatric concussions.

OBJECTIVE: To evaluate whether quantitative metrics of white matter fractional anisotropy (FA) and mean diffusivity (MD) were different in patients presenting to our clinic with persistent symptoms after a concussion. DESIGN: Matched control retrospective study. SETTING: Primary not-for-profit Institution. PATIENTS: Consecutive patients seen at a primary care institution's Sports Concussion Clinic for sport-related concussion that underwent diffusion tensor imaging. Interventions (Independent variables): Type of sports, days from Injury, number of symptoms, weeks out when Magnetic Resonance Imaging (MRI) ordered, history of psychological issues, length of symptoms, age, sex, MRI imaging data. MAIN OUTCOME MEASURE: Difference in white matter FA and MD. RESULTS: Seventeen concussion patients, ages 9 and 17 (average = 12.5 years; median = 13 years, 11 males and 6 females), were matched with age and gender controls who had an MRI following a complaint of headache. Patients reported an average of 11.5 concussion symptoms, out of a total possible 22 and were seen at an average of 30 days post injury. No region met tract based spatial statistics criteria for significant differences between concussed and healthy control groups (all p > 0.05). Similarly, when comparing group averages from the atlas based regional summaries, no region met the 0.2 false discovery rate (FDR) threshold for significant differences (the smallest unadjusted p-values were 0.02 for MD and 0.14 for FA). CONCLUSIONS: Our results did not show measurable diffusion tensor imaging (DTI) changes with standard clinical data acquisition and quantitative processing for the individual patient. At this time DTI should not be considered a technique that can diagnose concussion within an individual subject.