Overutilization of Radiographs for Pulled Elbow Among Orthopedic Surgeons Compared With Pediatricians.

METHODS: Electronic medical records of the largest health provider in Israel, which provides health services to more than 50% of the population, were reviewed for pulled elbow cases between 2005 and 2020. Patients aged 4.5 months to 7 years were included. Demographic information, the discipline of the treating physician, and acquisition of elbow radiographs were gathered. RESULTS: A total of 4357 patients, 62.8% girls, were included. The average body mass index was 16.1 (SD, 1.2). Most patients were from communities in the upper half of the socioeconomic status clusters 6 to 10 (64.63%). Most patients were attended by a pediatrician (51.5%), followed by an orthopedic surgeon (19.9%). Radiographs were acquired for 570 children (13.1%). Most radiographs (36.5%) were requested by orthopedic surgeons and for children in the boundary age groups. The patient's socioeconomic status was associated with access to physicians of different subspecialties, and lower income families had a higher tendency to be treated by nonspecialized physician ( P < 0.001). CONCLUSIONS: Orthopedic surgeons use elbow radiographs much more than pediatricians; effort should aim at reducing the imaging rate for this population.

Trampoline-related Injuries in Children: A Tertiary Pediatric Center Experience in Israel.

BACKGROUND: The growing popularity of trampoline jumping in the past years has led to an increase in trampoline-related injuries. The risk is particularly high in large trampoline parks, which are attended by many individuals of various sizes and ages. OBJECTIVES: To describe a tertiary pediatric center experience in Israel. METHODS: The database of a tertiary pediatric medical center was retrospectively reviewed for all trampoline-associated admissions to the emergency department in 2015-2018. Data were collected on patient demographics and injury characteristics with an emphasis on type and venue. RESULTS: Of the 23,248 admissions for orthopedic trauma during the period, 244 children were admitted for 246 trampoline-related injuries. Injuries involved the lower limb in 130 children (53%), upper limb in 87 (36%), spine in 20 (8%), and other sites in 9 (3%). Almost half of the injuries (113/246, 46%) were fractures, 27% required either closed or open reduction in the operating room. Large trampoline centers were responsible for half of the cases. CONCLUSIONS: Trampoline injuries accounted for 1.05% of all emergency department admissions at a tertiary pediatric hospital in 2015-2018. Nearly half of the trampoline-related injuries were fractures. Large trampoline centers pose a potential risk for more serious injuries. We raise awareness of the risks of trampoline jumping, considering increasing popularity of trampoline parks, and encourage the authorities to implement safety regulations.

Scoliosis in Non-Ambulatory Cerebral Palsy: Challenges and Management.

BACKGROUND: In non-ambulatory patients with cerebral palsy, the presence of scoliosis has a major impact on health and quality of life. The aim of this review is to raise awareness of caregivers from various professions to the extent of the problem, to explain the natural history of neuromuscular scoliosis and its pathophysiology, and to describe up-to-date optional conservative and surgical treatments.

Fractures and refractures after femoral locking compression plate fixation in children and adolescents.

BACKGROUND: Locking compression plates (LCPs) are being increasingly utilized in fixation of fractures and osteotomies in the pediatric population. However, plate insertion or removal may pose a risk of femoral fractures or refractures. The goal of this study was to analyze failure patterns associated with LCPs and identify possible contributing factors. METHODS: The sample included all patients who underwent fixation of femoral fractures or osteotomies utilizing straight LCPs at a tertiary pediatric medical center from 2004 to 2009. All were followed up until fracture union. The charts and radiographs were reviewed, and data on demographics, indications, surgical technique, and timing of plate removal were summarized. In cases of failure, the timing, circumstances, fracture location, and refixation method were recorded. RESULTS: Thirty-seven patients underwent 41 straight LCP fixations during the study period. The indication for surgery was acute femoral fracture in 25 procedures (25 patients) and elective osteotomy or limb lengthening in 16 procedures (12 patients). Thirty-five plates were removed after complete clinical and radiographic union. The time from plate fixation to removal averaged 13 months (range, 5 to 34 mo) in the fracture group and 17.6 months (range, 7.5 to 28 mo) in the osteotomy group. Five procedures (12%) were complicated by femoral fractures or refractures: 2 occurred after the index surgery-1 at the proximal screw and 1 through the original fracture site, with plate breakage. Three patients sustained refractures after plate removal, all at the original fracture or regenerate site: 1 after a fall and 2 spontaneously. The average time from plate removal to refracture was 18 days (range, 10 to 30). There were no differences in demographics, timing, or technique between patients with and without complications. CONCLUSIONS: Although LCPs are considered flexible fixators, they may carry the risk of overstiffness, similar to external fixators. Further clinical and biomechanical studies are needed to evaluate risk factors for fractures or refractures, particularly in children. There seems to be an increase in risk of refracture immediately after plate removal. Caution should be taken in the first weeks after plate removal. LEVEL OF EVIDENCE: Level IV.

Short-term after-effect of forearm cast removal in children.

PURPOSE: To investigate the sensation in the hand after forearm cast removal in children. METHODS: The study group included 33 consecutive children who were treated nonoperatively for a forearm fracture at our center over a 1-year period. The children were asked to report any sensation in the ipsilateral hand after cast removal, and the findings were analyzed against background and fracture-related data. RESULTS: The patients ranged in age from 6 to 14 years (median 10.00 years). Seventeen had been immobilized in an above-elbow cast and the remainder in a below-elbow cast. All children treated with an above-elbow cast complained that after cast removal, the hand on that side felt limp, and they had to hold it with the contralateral hand. By contrast, only one child treated with a below-elbow cast reported this sensation (p = 0.0001, Fisher exact test). CONCLUSIONS: Orthopedic surgeons and rehabilitation unit staff should be aware of the possibility of a very short-term sensation of drooping and weakness of the hand after removal of an above-elbow cast in children and prepare the child and parents accordingly in order to lessen unnecessary anxiety.

Intraoperative C-arm radiation affecting factors and reduction by an intervention program.

BACKGROUND: The increase in the utilization of fluoroscopy during surgical procedures carries with it an inherent increase in the exposure of both patients and surgical staff to ionizing radiation. The purpose of this study was to examine the ability to reduce radiation doses by the implementation of an intervention program targeted at the staff operating the fluoroscopy machinery and attempting to make a behavioral change in its utilization. METHODS: (1) Fluoroscopy technique was optimized after a series of simulation fluoroscopies. (2) A series of lectures was given to all staff operating fluoroscopy equipment (surgeons and x-ray technicians). (3) Directives for the reduction of radiation were included in the preoperative briefing, a sign was displayed next to the fluoroscopy screen, and radiation data was discussed in postoperative conferences. The index procedure chosen for the study was closed reduction and percutaneous fixation of Gartland III supracondylar humerus fractures. Fluoroscopy time and dosage were compared in 43 cases before the intervention program (group A) and in 40 cases after the program (group B). Reduction accuracy was assessed by the Bauman angle, humerocapitellar angle, and rotation index. RESULTS: The mean fluoroscopy time was 122 seconds (6-565) in group A and 54 seconds (1-188) in group B with a P value of 0.001. Radiation emission was 202 (5-1210) millirems in group A and 90 millirems (10-237) in group B (P=0.005). The mean fluoroscopy time for a surgery performed by a resident was 126 seconds (27-431) with 211 (38-766) millirems of radiation. The presence of a senior surgeon reduced these figures to 75 seconds (1-565) (P=0.003) and 127 millirems (5-1210) (P=0.001). The effect of the intervention program was similar regardless of the level of training of the surgical staff. Reduction accuracy and complication rate were no different in the 2 groups. CONCLUSIONS: Radiation exposure is significantly affected by surgical and fluoroscopic techniques and by the surgeons' level of training. Exposure can be decreased significantly by awareness and behavioral modification. LEVEL OF EVIDENCE: Level II therapeutic study.

Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic-impregnated cement rods.

BACKGROUND: Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. METHODS: Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Children's Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. RESULTS: Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. CONCLUSIONS: The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. LEVEL OF EVIDENCE: Therapeutic study, clinical case series: level IV.

Correction of lower limb deformities in children with renal osteodystrophy by the Ilizarov method.

BACKGROUND: Children with renal osteodystrophy (ROD) may develop severe angular deformities of the limbs. Various methods, both medical and surgical, have been described for correction of these deformities, but a literature search showed only 1 child previously treated by the Ilizarov method. The purpose of this study was to characterize the deformities found in our group of patients and to describe our experience in treating these patients with the Ilizarov method. METHODS: Correction of angular deformity by the Ilizarov method was performed on 8 limb segments in 5 patients with ROD. Mean age was 14.9 years. Two patients were on hemodialysis, and 3 had functioning kidney grafts. Surgery was deferred until stabilization of metabolic parameters. RESULTS: There was 1 varus and 7 valgus deformities. Preoperative coronal deformity averaged 29 degrees (18-38 degrees). The Ilizarov apparatus was used in all cases. Correction time averaged 23 days (20-28 days). The time from completion of correction to frame removal averaged 71 days (48-113 days). There were no changes in metabolic parameters or frequency of hemodialysis throughout the treatment. Restoration of a normal mechanical axis was achieved in 4 of the 5 patients. One case failed due to intraarticular instability. There were no major complications. Minor complications included pin tract infections, which responded to antibiotic treatment, and premature consolidation in 1 case. Follow-up averaged 6.5 years (1-10 years). The alignment obtained at surgery was maintained in all 4 patients, and they are functional and symptom-free. The patient for whom the surgery failed remains wheelchair-bound. CONCLUSIONS: The Ilizarov method was found to be safe and effective for correction of malalignment due to ROD. Optimization of metabolic parameters is essential before surgery and throughout correction. The procedure is contraindicated in patients with significant intraarticular knee pathology.

Botulinum toxin for the treatment of spasticity in children: attainment of treatment goals.

Forty patients (mean age 5 years) with a spastic disorder treated by botulinum injections (53 sessions) were evaluated for functional outcome in terms of achievement of their individual predetermined goals of treatment, rated on a modified Goal Attainment Scale from 1 (worsening function) to 4 (improved gross motor function). At the 2-week follow-up, 40% had a score of 1, 33% a score of 2, and 13% a score of 3; 12% showed no functional change. Botulinum treatments failed to significantly improve the gross motor function in this patient group. Treatment goals and expectations should clearly be established beforehand.

Subtrochanteric femoral fractures due to simple bone cysts in children.

Seven children were treated surgically as a result of a pathologic fracture through a simple bone cyst in the subtrochanteric region of the proximal femur. Average age at surgery was 10.6 years. Six children were treated primarily. One child was operated for a refracture through a persistent cyst and malunion of a previous fracture that had been treated nonoperatively. Surgery included curettage of cysts in all patients. The cysts were filled with autologous bone graft in five patients and Osteoset bone substitute in two patients. The fracture was stabilized using a blade plate in three patients, a screw and side plate in three patients and an external fixator in one. At average follow-up of 4.7 years, all fractures had healed uneventfully. The cyst was fully obliterated in five patients and partially obliterated in two patients. One patient had a relative lengthening of 2 cm on the affected side. All patients were asymptomatic, fully active and had full range of motion.

Percutaneous aspiration and irrigation technique for the treatment of pediatric septic hip: effectiveness and predictive parameters.

UNLABELLED: Septic arthritis of the hip has been treated traditionally by surgical drainage. Recent reports have described repeated aspirations as an adequate and safe treatment. The aim of the present study was to assess the success of treatment of septic arthritis of the hip by repeated aspirations and to identify predictive factors for failure. Medical records were retrospectively reviewed for all patients treated by ultrasound-guided aspiration and intravenous antibiotics between 2002 and 2010. The demographic, clinical, laboratory, and outcome data were recorded. Findings were compared between patients who responded to this treatment and those who subsequently required surgery. A total of 42 patients fulfilled the inclusion criteria. Of the total 33 responded to repeated aspirations and nine required surgical drainage. The mean age of patients requiring surgery was 8.3 years compared with 2.6 years for those responding to aspirations. Age older than 10 years was associated with a 57% rate of failed conservative treatment compared with 14% for age younger than 10 years. There was no significant difference between the groups in any of the other parameters measured. Follow-up of the operated group after an average of 7.44 years showed no unfavorable results. In children with septic arthritis of the hip, hip decompression may be achieved with repeated aspirations and lavage combined with antibiotics, sparing patients the risks of anesthesia and surgery. Age older than 10 years at admission may serve as the cutoff for initial conservative treatment. The postponement of surgery did not cause any long-term morbidity. LEVEL OF EVIDENCE: Level III; patients compared on the basis of outcome of conservative treatment of septic hip arthritis.

Compartment syndrome because of acute hemorrhagic edema of infancy: a case report and literature review.

UNLABELLED: Acute hemorrhagic edema of infancy (AHEI) is a benign, self-limiting vasculitis that usually resolves completely without any sequelae or a need for active therapy. To our knowledge, compartment syndrome because of AHEI has not been reported. Chart data for a single case were reviewed and reported in a retrospective study. A 19-month-old male presented with petechial rash and swelling of the left lower leg. AHEI was diagnosed clinically and confirmed by skin biopsy. On the basis of the clinical appearance, compartment syndrome of the foot was suspected. Measurements of compartmental pressures in the foot were well above the commonly cited ranges and a fasciotomy was performed. Following the operation, there was a marked clinical improvement in the limb perfusion. The child was discharged on the 20th day with marked clinical improvement; both active and passive leg movements were intact. We suggest that pediatric orthopedic surgeons should be familiar with this entity and its rare complication. LEVEL OF EVIDENCE: V - case report.

Reference accuracy in peer-reviewed pediatric orthopaedic literature.

BACKGROUND: Reference accuracy of articles published in the biomedical literature is determined by the presence of citation and quotation errors. A recent review demonstrated that the median citation error rate per biomedical journal was 39%, and the median quotation error rate per journal was 20%. Reference accuracy in pediatric orthopaedic articles has not been previously reported, to our knowledge. METHODS: Two hundred references from twenty articles published in four peer-reviewed orthopaedic journals were randomly selected for assessment of citation and quotation accuracy. Full-text copies of all original references were obtained by interlibrary loan methods and reviewed directly to establish citation accuracy. The presence of citation errors was determined by a single investigator. The relevance of citation errors was determined by assessing the ease of reference retrieval through PubMed. Quotation accuracy was determined by two examiners who reviewed each of the twenty articles and 200 references to compare the claims made for the references in the article against the data and opinions expressed in the actual reference. RESULTS: The total citation error rate across all of the journals was 26% (fifty-one of 200 references) with a 95% confidence interval of 16.5% to 37.3%. The median citation error rate per journal was 27% (range, 10% to 38%). Although citation errors were common, most were of minimal significance, as 196 of the 200 references could be retrieved with ease from PubMed. The total quotation error rate across all of the articles was 38% (152 of 398 reference citations) with a 95% confidence interval of 30.1% to 47.0%. The median quotation error rate per journal was 38% (range, 28% to 46%). CONCLUSIONS: Citation and quotation errors are common in the pediatric orthopaedic literature. Reference accuracy continues to be a substantial problem in the biomedical literature despite recent technological advances such as online databases, easily accessible search engines, and widely available bibliographic software.

Corrective lower limb osteotomies in children using temporary external fixation and percutaneous locking plates.

BACKGROUND: We describe a new method for corrective osteotomy and the fixation of lower limb deformities in children. METHODS: Following osteotomy, the desired position is obtained and temporarily stabilized using an external fixator. Definitive fixation is performed with a plate and locking screws inserted percutaneously under fluoroscopic guidance. The procedure was performed in 18 segments in 11 patients. Corrections were performed in all planes. RESULTS: The mean follow up was 18 months (range 6-36 months). All patients were corrected to within 2 degrees of that which was planned. Union was obtained in 16 segments in ten patients within 6-16 weeks. CONCLUSIONS: The method was found to be effective for the correction of deformity in the pediatric population. Advantages compared to conventional methods include minimal soft tissue dissection and the ability to adjust the position before definitive fixation.

Treatment of severe early onset Blount's disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame.

PURPOSE: Severe Blount's disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity. METHODS: Four patients were treated for severe Blount's disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest. RESULTS: Mechanical axis was corrected from a mean 23 degrees (13 degrees -30 degrees ) to 0 degrees in three patients and 6 degrees valgus in 1. Tibias were lengthened by 1-4 cm. At follow-up, the mechanical axis was 0 degrees in two patients and 7 degrees varus in two. The overlengthening was diminishing as planned. CONCLUSIONS: The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount's disease.

Children's daily living activities during immobilization of upper-limb fractures with an above- or below-elbow cast.

BACKGROUND: The purpose of this prospective study was to assess the impact of cast immobilization on the activities of daily living in children with fractured upper limbs. METHODS: Using the Activities Scale for Kids (ASK), 52 consecutive children (17 girls, 35 boys), aged 5-15 years (mean, 9 years), with upper limb fractures treated by means of above- or below-elbow casts were assessed. The files were reviewed for background and fracture-related data. RESULTS: Mean score of the above-elbow group was 65.4 +/- 15.5 points on the ASK capability domain (ASK-c) (with cast) and 98.7 +/- 3 points on the ASK-performance domain (without cast). Corresponding scores for the below-cast group were 89.8 +/- 13 and 99.5 +/- 2. Factors that positively affected overall function were older age, male sex, shorter duration of pain, and less displacement. On multivariate analysis, only age proved to be a potential predictive factor. Cast position and hand dominance had no effect. The specific activities affected were personal hygiene, dressing, making a snack, and reaching high objects. CONCLUSIONS: To ease their children's adjustment to forearm cast immobilization after fractures, parents should be educated in the areas of daily living that may be affected. This is particularly true for younger children with more displaced fractures that cause more pain.

Are frequent radiographs necessary in the management of closed forearm fractures in children?

INTRODUCTION: A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China. METHODS: The sample consisted of 202 consecutive children (mean age 7 years; range 3-12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4-6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15 degrees ) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal. RESULTS: Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15 degrees on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients. CONCLUSIONS: On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.

Small-fragment wounds from explosive devices: need for and timing of fragment removal.

The management of soft tissue small-fragment wounds caused by bombs remains controversial. The authors analyzed the outcome of low-energy foreign body injuries in 10 pediatric victims of suicide bomber attacks treated in their institution over a 2-year period. Two died during primary surgery. The eight survivors underwent a total of 10 procedures for removal of foreign bodies. Average follow-up was 24.1 months. The indications for the procedures were analyzed by the time of their performance: immediate, as part of the primary emergency operation (n = 2); intermediate, within 2 weeks after injury (n = 3); and late, more than 2 weeks after injury (n = 5). The results showed that all operations performed for objective indications were done within the immediate or intermediate period, whereas those done for subjective reasons were all but one performed in the late period. By the final follow-up visit, all foreign bodies had been removed. In conclusion, fragment removal is best done during the primary procedure if it does not pose a significant risk of complications.