Pediatric Firearm Trauma on the Rise: A Retrospective Review of Over 1,100 Cases in 12 Years at One Center.

BACKGROUND: Gunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas. METHODS: This study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner's office. RESULTS: Between 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns. CONCLUSIONS: This data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence. LEVEL OF EVIDENCE: Level II Prognosis study.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

OBJECTIVES: To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. DESIGN: Prospective observational cohort. SETTING: Eight tertiary care pediatric centers. PATIENT SELECTION CRITERIA: Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. OUTCOME MEASUREMENTS AND COMPARISONS: Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. RESULTS: Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). CONCLUSIONS: In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Severely Shortened or Comminuted Clavicular Fractures in Older Adolescent Athletes.

BACKGROUND: Recent evidence suggests that for completely displaced midshaft clavicular fractures, surgery offers no clear benefit over nonoperative treatment in a general adolescent population from 10 to 18 years of age. However, the comparative outcomes of comminuted and/or severely shortened clavicular fractures specifically in older adolescent athletes have not been explored in a focused, methodologically rigorous fashion. HYPOTHESIS: The study hypothesis was that outcomes would be superior in older adolescent athletes who underwent operative treatment compared with nonoperative treatment for comminuted and/or severely shortened clavicular fractures. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A level 2, multicenter, prospective cohort study investigating the outcomes of midshaft fractures in adolescents between 2013 and 2017 was filtered to analyze the subcohorts of athletes 14 to 18 years of age with either fracture comminution or fracture shortening of ≥25 mm or both. Patient characteristics, injury mechanisms, fracture characteristics, and treatments were compared. Complications, rates, timing of return to sports (RTS), and patient-reported outcomes (PROs) were analyzed. RESULTS: The 2 treatment groups, which included 136 older adolescent athletes (69 nonoperative, 67 operative), showed similar distributions of primary sport type, competition level, comminution, shortening, and 2-year PRO response rate (n = 99; 73%). The operative group demonstrated 3 mm-greater mean superior displacement, which was therefore statistically controlled for as a confounder in the comparative PRO analysis. No 2-year differences in nonunion, delayed union, symptomatic malunion, refracture, clinically significant complications, or rates of RTS were detected between treatment groups. The difference in timing of RTS (operative, 10.3 weeks; nonoperative, 13.5 weeks) was statistically significant. After controlling for the minor difference in superior displacement, regression analysis and matched comparison cohorts demonstrated no differences between the nonoperative and operative groups in mean or dichotomized PRO scores. CONCLUSION: In this prospective, multicenter cohort study investigating older adolescent athletes with comminuted and/or severely shortened clavicular fractures, contrary to the study hypothesis, there were no differences in complications, RTS, or PROs between nonoperatively and operatively treated patients at 2 years. Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment.

Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.

PURPOSE: This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice. METHODS: Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate. RESULTS: Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023). CONCLUSION: Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS. LEVEL OF EVIDENCE: Therapeutic Level III.

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

BACKGROUND: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. METHODS: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. RESULTS: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. CONCLUSION: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.

Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases.

BACKGROUND: The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS: A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS: Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS: Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE: Level IV-case series.

Descriptive Epidemiology of Adolescent Clavicle Fractures: Results From the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study.

BACKGROUND: The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased. PURPOSE: To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]). STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll. RESULTS: A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation. CONCLUSION: Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011.

INTRODUCTION: Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011). METHODS: A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey. RESULTS: Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001). DISCUSSION: Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011. LEVEL OF EVIDENCE: Level IV. Type of evidence: therapeutic.

Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction.

Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.

Operating Room Personnel Determine Efficiency of Pediatric Spinal Fusions for Scoliosis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To investigate the effect of different surgeons, anesthesiologists, and cRNAs individually and in teams on various perioperative and operative time intervals in a large, high-volume children's hospital. SUMMARY OF BACKGROUND DATA: Along with individual factors, studies have indicated that team factors play a role in efficiency, with larger teams leading to increased procedure times. An operating room (OR) staff dedicated to orthopedics has been reported to decrease turnover time; however, the characteristics and behaviors of surgical team members, to our knowledge, have not been analyzed as possible factors contributing to pediatric OR efficiency, and limited research has been conducted in the field of orthopedic personnel. METHODS: Chart review identified consecutive pediatric and adolescent patients who had primary posterior spinal fusion (PSF) of ≥7 levels for correction of spinal deformity. Time intervals and delays were recorded based on previous studies looking at OR efficiency and adjusted to the specific time points available in our perioperative nursing records. RESULTS: Adjusted for etiology, osteotomy, fusion levels, distance from hospital, staff switch, and body mass index, there was a significant difference in patient wait time among anesthesiologists, surgeon-anesthesiologist, and anesthesiologist-certified registered nurse anesthetist (cRNA) teams; in surgery prep time and total prep among surgeons and SA teams; and in surgery time and total room time among surgeons. There were no significant differences among cRNAs, individually, in any time interval. CONCLUSIONS: Anesthesiologists have a significant effect before and surgeons have a significant effect after entry into the OR. Identification of this variability provides an opportunity to study the differences in habits and processes of high- and low-efficiency teams, which can then be applied to all teams with the goal of improving performance of all surgical teams. LEVEL OF EVIDENCE: Level IV, case series.

Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery.

INTRODUCTION: Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH. METHODS: A multicenter retrospective review of all children who underwent surgical arthrotomy for presumed SAH over a ten-year period was conducted. Variables queried included demographics, clinical presentation, laboratory parameters, imaging, infecting organism, presence of osteomyelitis, and surgical interventions performed. Logistic regression was used to predict the risk of a second procedure. Chi-square was used to compare patients who required further surgery and those who did not. RESULTS: One hundred and thirty-eight patients (139 hips) qualified for inclusion. The average age at initial surgery was 6.1 years (range, zero to 17 years), and 57% of the patients were male. Concomitant osteomyelitis was diagnosed in 55 cases (40%). An infecting organism was identified from 70 (50%) index intraoperative cultures, with Staphylococcus aureus infections (methicillin-resistant Staphylococcus aureus [MRSA], 27; methicillin-sensitive Staphylococcus aureus, 25) being the most frequent. Fifty-six patients (41%) underwent subsequent surgical intervention, at an average of 5.5 days (range, 2 to 95) from the index procedure. Independent risk factors for repeat surgical procedures included presenting C-reactive protein >10 mg/dL (P = 0.002) and presenting erythrocyte sedimentation rate >40 (P = 0.011). The odds of repeat surgical intervention were significantly increased by the presence of concomitant osteomyelitis (odds ratio, 3.4; P = 0.001) and positive index intraoperative cultures for MRSA (odds ratio, 1.19; P = 0.001). Preoperative MRI before the index procedure was not universal (73/138; 53%), and acquisition of preoperative MRI was not associated with secondary surgical intervention (P = 0.389). DISCUSSION: Forty-one percent of children in this multicenter cohort underwent at least one repeat surgical procedure after the index arthrotomy for management of presumed SAH. Risk factors for return to the operating room include elevated initial erythrocyte sedimentation rate and C-reactive protein, infection with MRSA, and presence of osteomyelitis. LEVEL OF EVIDENCE: Level 3, case-cohort series. Type of evidence, therapeutic.

Surgical Treatment of Supracondylar Humeral Fractures in a Freestanding Ambulatory Surgery Center is as Safe as and Faster and More Cost-Effective Than in a Children's Hospital.

BACKGROUND: Despite an 88% increase in the number of pediatric fractures treated in ambulatory surgery centers (ASCs) over a 10-year period, few studies have compared outcomes of fracture treatment performed in a freestanding ASC compared with those performed in the hospital (HOSP) or hospital outpatient department (HOPD). The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of Gartland type II supracondylar humeral (SCH) fracture in the ASC, HOSP, and HOPD. METHODS: Retrospective review identified pediatric patients with isolated Gartland type II SCH fractures who had closed reduction and percutaneous pinning (CRPP) by board-certified orthopaedic surgeons from January 2012 to September 2016. On the basis of the location of their treatment, patients were divided into 3 groups: HOSP, HOPD, and ASC. All fractures were treated with CRPP under fluoroscopic guidance using 2 parallel or divergent smooth Kirschner wires. Radiographs obtained before and after CRPP and at final follow-up noted the anterior humeral line index (HLI) and Baumann angle. Statistical analysis compared all 3 groups for outcomes, complications, treatment time/efficiency, and charges. RESULTS: Record review identified 231 treated in HOSP, 35 in HOPD, and 50 in ASC. Radiographic outcomes in terms of Baumann angle and HLI did not differ significantly between the groups at any time point except preoperatively when the HLI for the HOSP patients was lower (P=0.02), indicating slightly greater displacement than the other groups. Overall complication rates were not significantly different among the groups, nor were occurrences of individual complications. The mean surgical time was significantly shorter (P<0.0001) in ASC patients than in HOPD and HOSP patients, and total charges were significantly lower (P<0.001). CONCLUSIONS: Gartland type II SCH fractures can be safely treated in a freestanding ASC with excellent clinical and radiographic outcomes equal to those obtained in the HOSP and HOPD; treatment in the ASC also is more efficient and cost-effective. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Adolescent clavicle nonunions: potential risk factors and surgical management.

BACKGROUND: Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes. METHODS: A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture. RESULTS: There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture. CONCLUSIONS: Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft.

Factors that predict instability in pediatric diaphyseal both-bone forearm fractures.

The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.

Orthobiologics in Pediatric Sports Medicine.

Orthobiologics are biological substances that allow injured muscles, tendons, ligaments, and bone to heal more quickly. They are found naturally in the body; at higher concentrations they can aid in the healing process. These substances include autograft bone, allograft bone, demineralized bone matrix, bone morphogenic proteins, growth factors, stem cells, plasma-rich protein, and ceramic grafts. Their use in sports medicine has exploded in efforts to increase graft incorporation, stimulate healing, and get athletes back to sport with problems including anterior cruciate ligament ruptures, tendon ruptures, cartilage injuries, and fractures. This article reviews orthobiologics and their applications in pediatric sports medicine.

Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature.

BACKGROUND: Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. METHODS: A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. RESULTS: Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. CONCLUSIONS: Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes. LEVEL OF EVIDENCE: Level III-systematic review of level III/IV studies.

Levels of Evidence in the Journal of Pediatric Orthopaedics: Update and Comparison to the Journal of Bone and Joint Surgery.

BACKGROUND: Periodic review of the published research in pediatric orthopaedics is helpful to evaluate the state of scientific methodology. The purpose of this paper was to review the levels of evidence (LOE) and types of evidence (TOE) published in the Journal of Pediatric Orthopaedics (JPO) from 2009 to 2013 and to compare the percentage of articles with each LOE to pediatric orthopaedic articles published in the Journal of Bone and Joint Surgery-American Volume (JBJS) during the same time. METHODS: All articles published in JPO from January 1, 2009, to December 31, 2013, were reviewed. Articles were classified as scientific studies, case reports, commentaries/letters to editor, reviews, expert opinion, and basic science articles. All scientific articles in the pediatrics section of the online version of JBJS were reviewed. If listed, the LOE was recorded from all clinical scientific studies. In addition, articles were abstracted for self-reported TOE (therapeutic, diagnostic, prognostic, or economic analysis). RESULTS: We found 850 citations in JPO over the study period; 646 (76%) were identified as scientific articles and, of those, 552 (85%) had a LOE listed. There were 18 level I articles (3%), 101 level II (18%), 184 level III (34%), and 289 level IV (45%). The TOE was listed in 213 (39%) articles: 114 (54%) therapeutic, 37 (17%) prognostic, 55 diagnostic (26%), and 7 (3%) economic analysis. Comparing 2009 to 2013, the percentage of scientific studies with a self-reported LOE improved significantly (from 81% to 93%, P=0.001). Compared with JPO, JBJS had a significantly higher rate of level I (12% vs. 3%, P=0.006) and a significantly lower rate of level III (23% vs. 34%, P=0.01) articles. CONCLUSION: From 2009 to 2013, 3% of articles in JPO were level I. Significantly more articles are now including a level of evidence designation. Approximately half of published studies are level IV, and most are therapeutic type. A higher percentage of level I studies were published in JBJS during the same time period.

Accessibility and quality of online information for pediatric orthopaedic surgery fellowships.

BACKGROUND: Pediatric orthopaedic fellowship applicants commonly use online-based resources for information on potential programs. Two primary sources are the San Francisco Match (SF Match) database and the Pediatric Orthopaedic Society of North America (POSNA) database. We sought to determine the accessibility and quality of information that could be obtained by using these 2 sources. METHODS: The online databases of the SF Match and POSNA were reviewed to determine the availability of embedded program links or external links for the included programs. If not available in the SF Match or POSNA data, Web sites for listed programs were located with a Google search. All identified Web sites were analyzed for accessibility, content volume, and content quality. RESULTS: At the time of online review, 50 programs, offering 68 positions, were listed in the SF Match database. Although 46 programs had links included with their information, 36 (72%) of them simply listed http://www.sfmatch.org as their unique Web site. Ten programs (20%) had external links listed, but only 2 (4%) linked directly to the fellowship web page. The POSNA database does not list any links to the 47 programs it lists, which offer 70 positions. On the basis of a Google search of the 50 programs listed in the SF Match database, web pages were found for 35. Of programs with independent web pages, all had a description of the program and 26 (74%) described their application process. Twenty-nine (83%) listed research requirements, 22 (63%) described the rotation schedule, and 12 (34%) discussed the on-call expectations. A contact telephone number and/or email address was provided by 97% of programs. Twenty (57%) listed both the coordinator and fellowship director, 9 (26%) listed the coordinator only, 5 (14%) listed the fellowship director only, and 1 (3%) had no contact information given. CONCLUSIONS: The SF Match and POSNA databases provide few direct links to fellowship Web sites, and individual program Web sites either do not exist or do not effectively convey information about the programs. CLINICAL RELEVANCE: Improved accessibility and accurate information online would allow potential applicants to obtain information about pediatric fellowships in a more efficient manner.

Surgical treatment of symptomatic accessory navicular in children and adolescents.

Although an accessory navicular (AN) is present in approximately 10% of the population, it rarely is symptomatic, and few cases necessitate operative intervention. When symptoms require surgical treatment, excision of the AN, with or without advancement of the posterior tibial tendon, usually is successful. We reviewed our records to evaluate the outcomes and complications of surgical treatment of AN. Retrospective chart review identified patients younger than 18 who were treated surgically for a painful AN between 1991 and 2012. Medical records and digital images were reviewed to determine demographic information, duration of symptoms before surgery, type of AN, presence of flatfoot deformity, type of surgery, length of follow-up, outcomes, and complications. Twenty-seven patients (32 feet) had either isolated excision (14 feet) or excision plus tendon advancement (18 feet). Overall, 28 (87.5%) of feet had excellent or good functional outcomes. There was no significant difference in outcomes between the 2 procedures, though there was a trend toward more complications and more reoperations after tendon advancement.