The Effect of Obesity on Pediatric Tibia Fractures.

Background: Childhood obesity affects nearly one fifth of all children in the United States. Understanding the unique injury characteristics and treatment of tibia fractures in this population has become increasingly important. This study aims to explore the different injury characteristics between tibia fractures in obese and non-obese children. Methods: 215 skeletally immature children aged 2-18 who sustained tibia fractures between 2007.2019 were retrospectively reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight versus overweight and obese. Chi-square or Fisher's exact test was used to compare differences in categorical outcome between the 2-category BMI class variables; Wilcoxon test was used to compare continuous outcomes. A multivariate logistic regression model was used to evaluate BMI associations while controlling for age, sex, race, and mechanism of injury. Results: Distribution of BMI in the cohort included 6.5% underweight, 45.6% normal weight, 16.7% overweight and 31.2% obese. Overweight and obese children sustained fractures from low energy mechanisms at more than double the rate of normal and underweight children (20.5% versus 9.7%, p=0.028). Overweight and obese children sustained physeal fractures at a rate of 54.4% in comparison with 28.6% in their normal and underweight peers (p<0.0001, OR 2.50 (95% CI, 1.26-4.95)). Overweight and obese children sustained distal 1/3 tibia fractures at a higher rate of 56.9% compared to under and normal weight children at 33.9% (p=0.003, OR 2.24 (95% CI, 1.17-4.30)). Overweight and obese children underwent unplanned changes in treatment at a lower rate than normal and underweight children at 1% versus 8% rates of treatment change, respectively (p=0.013, OR 0.076 (95%CI, 0.009-0.655)). No significant differences were found in the rates of operative treatment, repeat reduction, post treatment complications, or physical therapy. Conclusion: Overweight children sustain tibia fractures from low energy mechanisms at higher rates than their peers. Similarly, obese and overweight patients have higher rates of physeal injuries and higher rates of distal 1/3 tibia fractures. Complication rates are similar between obese and non-obese children undergoing treatment for tibia fractures. Level of Evidence: III.

Validation of a Cost-effective Cast Saw Simulation-based Educational Module to Improve Cast Removal Safety.

BACKGROUND: Inexperience in cast removal in the pediatric population can lead to a range of cast saw-related injuries. The purpose of this study is to validate a simple simulation-based wax model that is both reproducible and economical while providing a valuable tool that can be used to grade cast saw use performance in trainees. METHODS: Cylindrical wax models were used as an analog for a pediatric upper extremity. The wax models were casted in a proscribed reproducible fashion for consistency. Two groups, the first consisting of 15 experienced cast saw users and the second consisting of 15 inexperienced individuals, completed 4 sequential longitudinal cuts in the casted wax models. After removal of the cast material, marks left by the cast saw in the wax were counted and measured. Indentation length, maximum depth, and maximum width were measured on each wax model. The total length of the cast saw indentations per cast saw user was also calculated. RESULTS: For the inexperienced cast saw users, the average total length of the cast saw indentations was 526.56 mm, average maximum depth was 1.91 mm, and average maximum width was 3.24 mm. For experienced cast saw users, the average total length of the cast saw indentations was 156.57 mm with an average maximum depth of 1.06 mm and average maximum width of 2.19 mm. Receiver operating characteristic curves of the total number of errors, total error length, maximum error depth, and maximum error width show effective discrimination of experienced from inexperienced trainees. CONCLUSIONS: This study provides valid evidence supporting a cost-effective, time-efficient, and easily reproducible educational simulation module that can objectively measure cast saw the performance in trainees. This model demonstrates construct validity and can distinguish novice from experienced cast saw users. It is sensitive enough to identify mistakes even in the most experienced cast saw users, creating a platform that can provide performance-based feedback to cast saw users of all experience levels. LEVEL OF EVIDENCE: Level III-diagnostic test.

Nonoperative Management of Subclavian Artery Thrombosis in Pediatric Clavicle Fractures: A Case Report.

CASE: A 12-year-old patient presented after a fall onto her upper extremity. She was found to have a mildly displaced clavicle fracture with a subclavian artery thrombosis. Given the reconstitution of flow distal to the thrombosis, the patient was treated nonoperatively in consultation with vascular surgery with anticoagulation and a sling for immobilization. CONCLUSION: This case highlights the importance of a thorough neurovascular examination even in a mildly displaced fracture. Nonoperatively managed thromboses may be treated successfully without orthopaedic fixation or vascular intervention, although the natural history of this injury is likely not fully understood.

Decreasing Radiation Exposure in Pediatric Clavicle and Metatarsal Fractures: A QI Initiative.

BACKGROUND: Protecting the pediatric population from unnecessary medical radiation is an important public health initiative. Efforts have been made to reduce radiation exposure in the treatment of pediatric fractures without compromising quality of care. Using a standardized protocol for imaging of pediatric clavicle and metatarsal fractures is a reliable method for reducing pediatric radiation exposure in the management of these fractures. METHODS: In the year 2015, the senior author altered follow-up imaging practices for 2 common pediatric fractures: metatarsal and clavicular. Initial radiographic evaluation included the standard 3 views for metatarsal fractures and 2 views for clavicle fractures. This standard diagnostic procedure remained constant throughout the study. Follow-up x-rays from 2009 to 2014 routinely included 3 views of the foot and 2 views of the clavicle. The protocol was changed and from 2016 to 2019, follow-up x-rays for fractures routinely included 2 views of the foot and 1 view of the clavicle, thereby decreasing the number of x-rays utilized to manage these fractures. RESULTS: There was a significant reduction in the number of clavicle x-rays (P<0.001) and metatarsal x-rays (P=0.004) taken in follow-up between the time-periods. Median values for metatarsal views decreased by 1, matching the adjustment in protocol. In addition, the vast majority of clavicle fractures (90.80%) were managed with 1 follow-up view in 2016 to 2019 compared with 2 views (72.48%) from 2009 to 2014. CONCLUSIONS: This study achieved a reduction in radiation exposure in pediatric patients with nonoperatively managed clavicle and metatarsal fractures. Improving the quality of care of patients through decreasing the number of x-rays taken protects individuals from adverse side effects, as well as offers various public health benefits in terms of reduction in expenditures. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Coronal Remodeling Potential of Pediatric Distal Radius Fractures.

BACKGROUND: Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of coronal remodeling, via the distal radius physis, present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures. METHODS: A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture with over 10 degrees of angulation in the coronal plane during the healing process at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2009 to 2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling. RESULTS: In total, 36 patients with distal radius fractures with a mean age of 7.93 years (range, 4 to 12 y) at the time of injury were identified. The median peak angulation during the healing process in the coronal plane was 17 degrees (range, 12.4 to 30.4 degrees). The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 6.59 months (range, 2.5 to 8.72 mo). At final follow-up, the median coronal angulation was 3.35 degrees (range, 0.24 to 14.0 degrees). At the 95% confidence level, remodeling rates ranged from 2.00 to 2.59 degrees per month. The mean rate of coronal angulation remodeling from maximum angulation to final follow-up was 2.30 degrees per month. CONCLUSIONS: Distal radius fractures have a large capacity to remodel in the pediatric population. This remodeling occurs in a predictable and reliable manner, even in the coronal plane. On the basis of this study, coronal angulation was shown to remodel at a rate of at least 2 degrees per month for the first 6 months following the injury, which should likely continue at a similar rate for the first year after the injury. Repeat manipulation is not indicated in skeletally immature patients where the maximum coronal angulation is <24 degrees, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year after fracture. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Obesity's Influence on Operative Management of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: As childhood obesity remains an ongoing issue for the United States there has been an increasing number of studies detailing its effect on fracture complexity, management, and outcomes. This study utilizes a national database to examine whether obese children with supracondylar humerus fractures are more likely to require open reduction and internal fixation than nonobese children. METHODS: The Healthcare Cost and Utilization Project Kid's Inpatient Database of 2003, 2006, 2009, 2012 were queried for pediatric supracondylar humerus fractures [International Classification of Disease (ICD-9), 812.41] between 2 and 12 years. Patients were separated into those undergoing closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or both. Obesity was determined by comorbidity and ICD-9 coding (ICD-9, 278.00, 278.01). Univariable and multivariable logistic regression models were utilized with P<0.05 considered significant. RESULTS: Between 2003 and 2012, 31,905 patients between the ages of 2 and 12 years sustained supracondylar humerus fractures. In total, 105 patients (0.3%) were obese. A majority of patients, 27,658 (86.7%), underwent CRPP. Odds for ORIF increased in association with age, obesity, white race, and private insurance. Significant association was found between age and obesity (P<0.05) in those undergoing ORIF. Obese children between 2 and 7 years of age had no difference in ORIF or CRPP compared with normal-weight children. Those between 8 and 12 years who were obese were significantly more likely to undergo ORIF (OR, 4.29; 95% confidence interval, 1.78-10.36). CONCLUSIONS: Supracondylar humerus fractures sustained in obese children between 8 and 12 years are over 4 times more likely to require ORIF compared with normal-weight children of the same age. Providers should identify and counsel older obese children and their families regarding the potential for increased difficulty in fracture management that may require open surgical intervention. LEVEL OF EVIDENCE: Level IV-case series.

Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at controlling pain in children, especially in the treatment of fractures. Adult animal and adult clinical studies demonstrate conflicting evidence for the inhibitory relationship between NSAIDs and fracture healing. Published pediatric orthopaedic clinical studies do not demonstrate an inhibitory effect of ketorolac on bone healing. Little is known about the effects of any NSAID on bone formation in juvenile animals. This study investigates the effects of the NSAID ketorolac on fracture healing in a juvenile rat model. METHODS: Unilateral surgically induced and stabilized tibial shaft fractures were created in 45 juvenile (3 to 4 wk old) male Sprague-Dawley rats. Either ketorolac (5 mg/kg; n=24) or saline (0.9% normal saline; n=21) was then administered to the rats 6 d/wk by intraperitoneal injections. Animals were then randomly assigned into time groups and euthanized at 7 days (n=8 ketorolac, n=7 saline), 14 days (n=8 ketorolac, n=7 saline), or 21 days (n=8 ketorolac, n=7 saline) postfracture. Biomechanical analysis was performed using a custom-designed 4-point bending loading apparatus. Statistics for tibial stiffness and strength data were performed using software package Systat 11. Specimens were also evaluated histologically using hematoxylin and eosin staining. RESULTS: Strength and stiffness of all fractured tibiae increased over time from day 7 to day 21 regardless of treatment type. No statistical difference was found between the fractured tibiae strength or stiffness in the ketorolac or control-treated specimens at the same time point. In addition, the quality of the fracture callus was similar in both groups at each of the time points. CONCLUSIONS: In this study of a juvenile rat model with a stabilized tibia fracture, fracture callus strength, stiffness, and histologic characteristics were not affected by the administration of ketorolac during the first 21 days of fracture healing. CLINICAL RELEVANCE: The absence of inhibitory effects of ketorolac on early juvenile rat fracture healing supports the clinical practice of utilizing NSAIDs for analgesia in children with long bone fractures.

Imaging of the pediatric athlete: use and overuse.

This article highlights the unique patterns of sports-related injury of the upper extremity that radiologists are likely to encounter in children and adolescents. The injuries are classified as acute "use" injuries or chronic "overuse" injuries, and reviewed separately for the shoulder, elbow, and wrist. Recommendations for imaging strategies are provided and characteristic imaging findings are discussed and illustrated.

Use of the StepWatch activity monitor for characterization of normal activity levels of children.

Clinical and research measures for walking activity measure capacity and performance. Existing tools such as 3-dimensional gait analysis and validated gross motor instruments examine capacity but do not measure performance. We defined normal activity levels for 20 children ages 5-7 and 9-11 years using the StepWatch Activity Monitor (SAM). Average daily step counts varied widely by age and sex (mean 7604 +/- 2485), but the percent time spent at high, medium, and low levels of activity was very consistent regardless of age or sex of the child.