Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study.

BACKGROUND: Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM. METHODS: Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures. RESULTS: Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures. CONCLUSIONS: The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients. LEVEL OF EVIDENCE: Level III.

Biomechanical Analysis of Retrograde Flexible Intramedullary Nail Constructs in a Simulated Pediatric Femur Fracture Model.

BACKGROUND: Various flexible intramedullary nail (FIMN) constructs for pediatric femur fractures are described; however, no biomechanical study has compared stability of medial-lateral entry versus all-lateral entry retrograde nailing. Our purpose is to compare the rotational and bending stiffness of 2 different FIMN constructs and 2 different materials in a simulated pediatric femur fracture model. METHODS: Eighty adolescent-sized composite femurs were used to simulate transverse (40 femurs) and oblique (40 femurs) mid-diaphyseal fractures. Retrograde FIMN of the femurs was performed using either 3.5 mm titanium (Ti) or 3.5 mm stainless-steel (SS) flexible nails in 2 configurations: 2 "C"-shaped nails (CC) placed through medial and lateral entry sites or 1 "C"-shaped nail and 1 "S"-shaped nail (CS) placed through a single lateral entry site. Models were first tested in 10 cycles of axial rotation to ±1 N m of torque at a rate of 0.5 degrees/s under 36 kg of compression. Axial compression was performed and bending stiffness defined as the force required to achieve 10 degrees varus at the fracture site. RESULTS: No differences were noted in rotational stiffness comparing Ti and SS nails regardless of nail configuration or fracture pattern. Comparable rotational stability was found for CC and CS configurations with SS implants for both fracture patterns. The CS construct (0.60 N m/degree) was stiffer in rotation than the CC construct (0.41 N m/degree) with Ti implants in the transverse fracture model (P<0.005). SS nails provided greater bending stiffness than Ti nails in both oblique and transverse fracture patterns, regardless of nail construct. The all-lateral entry (CS) construct demonstrated statistically significant greater bending stiffness regardless of implant material or fracture pattern (P<0.03). CONCLUSIONS: An all-lateral entry (CS) FIMN construct demonstrated greater bending stiffness in both fracture patterns and materials. Ti and SS implants have comparable rotational stiffness in all fracture patterns and materials; however, SS nails were superior at resisting bending forces in both fracture patterns. CS nail configuration and SS implants demonstrated superior bending stiffness and rotational stiffness when compared with the more commonly used CC construct and Ti implants. LEVEL OF EVIDENCE: NA (biomechanical study).

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures.

BACKGROUND: It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces. METHODS: Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion. RESULTS: In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type. CONCLUSIONS: Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures. LEVEL OF EVIDENCE: Level II-comparative biomechanical study.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds.

BACKGROUND: Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures. METHODS: An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. RESULTS: A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients. CONCLUSIONS: Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion. LEVEL OF EVIDENCE: Therapeutic Level III.

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons.

BACKGROUND: Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons. METHODS: We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy. RESULTS: Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy. CONCLUSIONS: An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population. LEVEL OF EVIDENCE: Level III-retrospective cohort.

Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS: This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS: A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS: Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE: Level II-therapeutic.

Avascular Necrosis in the Contralateral Hip in Patients With Congenital Femoral Deficiency: A Report of 3 Cases.

BACKGROUND: Congenital femoral deficiency is an uncommon clinical entity. We report 3 patients who developed avascular necrosis of the hip in the long (normal) leg during longitudinal observation and/or treatment of congenital femoral deficiency. METHODS: Patients were identified in limb length discrepancy clinic and their charts were retrospectively reviewed for clinical and radiographic data collection. RESULTS: We describe the occurrence of idiopathic avascular necrosis in the normal limb in patients being followed for limb length discrepancy. CONCLUSIONS: Although no conclusion could be drawn about the etiology of the avascular necrosis, we describe a previously undocumented relationship between congenital femoral deficiency and avascular necrosis in the contralateral hip. This occurred in our congenital femoral deficiency population at a rate higher than expected compared with published incidences of avascular necrosis of the hip in children. LEVEL OF EVIDENCE: Level IV-case series.

Fracture Classification Does Not Predict Functional Outcomes in Supracondylar Humerus Fractures: A Prospective Study.

BACKGROUND: Few studies have prospectively assessed functional outcomes after the surgical management of supracondylar humerus fractures (SCHFXs) and the relationship between fracture pattern and ultimate patient outcome has never been prospectively evaluated. The purpose of this study was to prospectively evaluate fracture classification and functional outcome in children with extension SCHFXs using validated outcome measures. METHODS: An Institutional Review Board-approved prospective enrollment of consecutive patients with operative SCHFX was performed over a 3-year period. Fractures were classified by the treating surgeon using the modified Gartland classification. Functional outcome was assessed at final follow-up using the Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcome measure. Patients with flexion-type fractures, multidirectionally unstable fractures and those with <10 weeks follow-up were excluded from analysis. Statistical analysis was used to determine the relationship between fracture classification/pattern and functional outcome. RESULTS: Seven hundred fifty-two patients were enrolled during the study period. One hundred thirty-two patients with extension-type injuries (average age 6.7 y) completed functional outcome measures at an average follow-up of 12.4 weeks. Forty-five (34%) were type II fractures and 87 (66%) were type III fractures. Forty-five (34%) of the fractures were posteromedially displaced, 43 (33%) were posterolaterally displaced, and 44 (33%) were posteriorly displaced without coronal plane deformity. The average PODCI global functioning scale score and QuickDASH scores for the entire cohort were 93.6 and 11.4, respectively, indicating excellent function. No differences in outcome scores were noted between patients with type II and III fractures. No difference in outcome was identified based upon direction of fracture displacement. CONCLUSIONS: This is the first study to prospectively analyze fracture classification and functional outcome using validated outcome measures following the operative treatment of pediatric extension-type SCHFX. Children generally have excellent functional outcomes following the operative treatment of SCHFX. Garland classification and direction of displacement do not influence functional outcomes. LEVEL OF EVIDENCE: Level II-therapeutic.

Osteomyelitis is Commonly Associated With Septic Arthritis of the Shoulder in Children.

PURPOSE: To describe the clinical presentation, management, and outcomes of surgically treated septic arthritis of the shoulder in a pediatric population. METHODS: A retrospective chart review over 5 years of children with operatively managed septic arthritis of the shoulder was completed. Demographics, clinical presentation, symptoms duration, antibiotic regimen and duration, number of surgical procedures, and evaluation of laboratory value improvements were collected. Pretreatment and final radiographs were assessed. Causative organisms were reviewed. Patients were stratified in age groups to determine clinical variability based upon patient age. RESULTS: A total of 22 children, ages 15 days to 14 years (average 37.3 mo), were treated for septic arthritis of the shoulder from 2006 to 2010 at a single pediatric institution. All patients were managed with open anterior arthrotomy at an average of 1.95 days after initial orthopaedic consultation (range, 0 to 15 d). Multiple presenting signs were noted; the most common was decreased use (59%). Average admission laboratory values include C-reactive protein 10.6 (range, 0.3 to 41.6), erythrocyte sedimentation rate 62.8 (range, 11 to 107), and white blood cell count 14.9 (range, 5.9 to 31.7). Initial radiographs were read as normal in 12 patients, concern for osteomyelitis in 5, cortical irregularity in 4, effusion in 3, and neoplasm in a single child. Nineteen patients had a preoperative magnetic resonance imaging and 15 demonstrated an effusion, 15 had evidence of humeral osteomyelitis, 5 had a subperisoteal abscess, and 4 had soft tissue abscesses. Eight patients remained culture negative. The most commonly identified organism was methcillin-resistant Staphylococcus aureus (MRSA) (22.7%). The patients under 12 months of age revealed more diverse organisms at culture and were less likely to have MRSA. All patients averaged 1.55 (range, 1 to 5) surgical procedures and had an average hospital stay of 13.5 days. Intravenous antibiotics averaged 16.3 days followed by an average of 34 days of oral treatment. MRSA patients were significantly more likely to require multiple operations to eradicate the infection (P<0.02) and had a longer duration of intravenous antibiotic use (P<0.003). MRSA patients were more likely to have abnormal radiographs at final follow-up (P<0.03). CONCLUSIONS: Septic arthritis of the shoulder in children is commonly associated with adjacent osteomyelitis. Pediatric septic arthritis of the shoulder due to MRSA bacteria can have a more virulent course than other bacterial causes, but is a less commonly identified organism in the youngest patients. SIGNIFICANCE: To our knowledge, this is one of the largest series published concerning the treatment, course, and outcomes of pediatric septic arthritis of the shoulder. LEVEL OF EVIDENCE: Level III-therapeutic.

Quengel Casting for the Management of Pediatric Knee Flexion Contractures: A 26-Year Single Institution Experience.

BACKGROUND: Quengel casting was introduced in 1922 for nonsurgical treatment of knee flexion contractures (KFC) associated with hemophilic arthropathy. It consists of an extension-desubluxation hinge fixed to a cast allowing for gradual correction of a flexion deformity while preventing posterior tibial subluxation. The purpose of this study is to report 1 center's experience with this technique for the treatment of pediatric KFC. METHODS: A retrospective review was conducted over a 26-year period. All patients with KFC treated with Quengel casting were included. Demographic data, associated medical conditions, adjunctive soft tissue releases, complications, and the need for late surgical intervention were recorded. Tibiofemoral angle measurements in maximal extension were recorded at initiation and termination of casting, 1-year follow-up, and final follow-up. Success was defined as no symptomatic recurrence of KFC or need for subsequent surgery. RESULTS: Eighteen patients (26 knees) were treated for KFC with Quengel casting. Average age at initiation of casting was 8.1 years with average follow-up of 59.9 months. Fifteen knees (58%) underwent soft tissue releases before casting. An average of 1.5 casts per knee were applied over an average of 23.9 days. Average KFC before casting was 50.6 degrees (range, 15 to 100 degrees) which improved to 5.96 degrees (0 to 40 degrees) at cast removal (P<0.00001). Sixteen patients (22 knees) had 1-year follow-up or failed casting before 1 year. Of these, 11 knees (50%) had a successful outcome. Residual KFC of those treated successfully was 6.8 degrees (range, 0 to 30 degrees) at 1 year and 8.2 degrees (range, 0 to 30 degrees) at final follow-up, averaging 71.4 months (P=0.81). Of the 11 knees deemed failures, all had recurrence of deformity within an average of 1 year from cast removal. Surgical release before Quengel casting did not improve the chances for success (P=0.09). CONCLUSIONS: Quengel casting can improve pediatric KFC an average of 44.2 degrees with minimal complications. Although 50% of treated patients will demonstrate significant recurrence or need later surgery, the majority of those treated successfully have durable results at intermediate term follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures.

PURPOSE: The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures. METHODS: An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes. RESULTS: In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation. CONCLUSIONS: In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal." LEVEL OF EVIDENCE: Level III.

Two Techniques for Retrograde Flexible Intramedullary Fixation of Pediatric Femur Fractures: All-Lateral Entry Versus Medial and Lateral Entry Point.

BACKGROUND: Multiple techniques for flexible intramedullary nailing (FIMN) of pediatric femur fractures have been described. To our knowledge, no study has compared combined medial-lateral (ML) entry versus all-lateral (AL) entry retrograde nailing. This study compares surgical outcomes, radiographic outcomes, and complication rates between these 2 techniques. METHODS: A retrospective review of a consecutive series of patients treated by retrograde, dual FIMN of femur fractures was performed from 2005 to 2012. Demographics and operative data were recorded. Radiographs were analyzed for fracture pattern, fracture location, percent canal fill by the nails, as well as shortening and angulation at the time of osseous union. Rates of symptomatic implants and their removal were noted. Data were compared between patients treated with medial and lateral entry (ML group) nailing and those treated with all-lateral entry (AL group) nailing using the Student t test and correlation statistics. RESULTS: Of the 244 children with femoral shaft fractures treated with retrograde FIMN using Ender stainless steel nails, 156 were in the ML group and 88 were in the AL group. There were no statistical differences in sex (74% vs. 82% males), age (8.0 vs. 8.6 y), weight (29.4 vs. 31.1 kg), or fracture pattern between the 2 groups. The average total anesthesia time was less in the AL group (133 vs. 103 min) (P<0.0001). There was no difference between the techniques in shortening (3.9 vs. 3.0 mm), coronal angulation (2.9 vs. 2.6 degrees), or sagittal angulation (3.3 vs. 2.7 degrees) at union. In the AL group, there was a correlation between canal fill and reduced shortening at union. No differences were found in the presence or degree of varus alignment, procurvatum deformity, or recurvatum angulation between the constructs. There were 5 malunions in the AL group and 9 malunions in the ML group (5.7% vs. 5.8%, P=1). The incidence of having a healed femur fracture with >10 degrees of valgus was higher in the AL group (0% vs. 3.4%) (P=0.04). There were no differences between the groups in the rate of symptomatic implant removal or surgical complications. CONCLUSIONS: The AL entry technique for FIMN of pediatric femur fractures is 30 minutes faster without worse final fracture alignment, additional complications, or increased rates of symptomatic implants. When using the AL technique, specific attention should be paid to percentage of canal fill and ensuring that the fracture is not reduced in a valgus position. LEVEL OF EVIDENCE: Level III-therapeutic.

The Effects of Restraint Type on Pattern of Spine Injury in Children.

INTRODUCTION: While the use of vehicular restraints has reduced the morbidity and mortality of children involved in motor vehicle collisions (MVC), to our knowledge, no study has examined the relationship between restraint type and patterns of pediatric spinal injuries. The purpose of this study is to evaluate this association and review the spinal injuries sustained in children involved in MVC. METHODS: We completed an IRB-approved, retrospective chart review of all patients below 10 years of age presenting to a level 1 pediatric trauma hospital with spine injuries sustained in MVC from 2003 to 2011. We reviewed prehospital data, medical records, and radiographs to establish the restraint type and characterize the spinal injuries sustained. RESULTS: A total of 97 patients were identified with spinal trauma secondary to MVC with appropriate and documentation of restraint type. Results are reported regardless of whether the restraint employed was properly used per established guidelines. Car seat/booster seat (C/B) patients sustained significantly higher rates of cervical spine (62%) and ligamentous (62%) injuries than the 2-point (2P) (10%) and 3-point (3P) restraint (24%) groups (P<0.001). Two-point and 3P restraint use was associated with significantly higher rates of thoracolumbar injuries (67% and 62%, respectively) than the C/B (14%) and unrestrained (0%) groups (P<0.001). Two-point and 3P passengers also had a higher rate of flexion-distraction injuries (P<0.001). Patients in the unrestrained group sustained a significantly higher rate of cervical spine (80%) and ligamentous (40%) injuries than the 2P and 3P groups (P<0.001). No differences were found in the type or location of injury between the 2P and 3P groups. Significant differences in proper restraint use were identified between age groups with younger children demonstrating higher rates of proper restraint use (P<0.01). CONCLUSIONS: Two-point or 3P seatbelt use is associated with lower rates of cervical spine trauma but higher rates of thoracic and lumbar trauma, particularly flexion-distraction injuries, when compared with car or booster seats. Children in C/B and those who are unrestrained sustain high rates of cervical spine injury. LEVEL OF EVIDENCE: Level III-prognostic study.

Outcomes After Surgical Treatment of Adolescent Intra-articular Distal Humerus Fractures.

BACKGROUND: To determine the radiographic and clinical outcomes of the surgical management of adolescent intra-articular distal humerus fractures. METHODS: We performed a retrospective review of the clinical and radiographic outcomes of 31 consecutive adolescent patients surgically treated for acute distal humerus intra-articular fractures. Nine patients returned for objective measures of range of motion, strength testing, and completion of validated outcome scores including the Mayo Elbow Performance Score (MEPS); The Disabilities of the Arm, Shoulder, and Hand Score (DASH); and the SF-36. RESULTS: The average age at the time of injury was 13.5 years (range, 12 to 16 y) with a mean follow-up of 1.22 years (range, 9 d to 5.5 y). Multiple surgical approaches were performed. Overall, the active range of motion for our patients was 10.7 to 133.9 degrees with a mean arc of 123.4 degrees. AO classification type C2 and C3 injuries lost significantly more motion than other fracture patterns. Twelve patients sustained perioperative nerve palsies that resolved by final follow-up; seven of these nerve injuries were iatrogenic and sustained during a Bryan-Morrey tricepital slide approach. Eight patients required implant removal; 7 of these patients had prominent olecranon screws after an olecranon osteotomy. Including postoperative neuropathies, there were 20 complications in 15 patients. Thirteen complications in 9 patients required a return to the operating room. Of the 9 patients who returned for objective testing, there was no statistically significant loss of range of motion or strength of the injured extremity when compared with the uninjured limb. The MEPS revealed 6 excellent, 1 good, and 2 fair results. The average DASH score was 5.1 (range, 0 to 19.1) and the physical (average 55.7; range, 47.4 to 59.0) and mental components (average 54.2; range, 29.8 to 63.4) of the SF-36 were comparable. CONCLUSIONS: After surgical intervention for an adolescent intra-articular distal humerus fracture, one can expect no significant loss of motion or strength. The reported outcomes are not all excellent. The peri-operative complication rates are high and may be related to surgical approach and fracture pattern. LEVEL OF EVIDENCE: Level IV.

Complications Associated With High-dose Corticosteroid Administration in Children With Spinal Cord Injury.

BACKGROUND: Complications with high-dose steroid administration for spinal cord injury are documented in adult patients. Our purpose was to determine the incidence of early complications of this therapy in pediatric patients with spinal cord injuries. METHODS: An IRB-approved retrospective review was performed for patients treated for spinal cord injury at a level 1 pediatric trauma center between 2003 and 2011. Demographic data, injury characteristics, and surgical interventions were documented. Complications were divided into 4 categories: infectious, gastrointestinal (GI), hyperglycemia/endocrine, and wound healing problems. Complication rates were compared using a Student's t test and Fischer's exact test. RESULTS: Thirty-four spinal cord injury patients were identified. Twenty-three patients (mean age 6.6 y) in the treatment group received high-dose steroid treatment and 11 patients (mean age 8.4 y) did not and comprised the control group. No statistical difference was detected between the 2 groups regarding age, mechanism of injury, rate of surgical intervention, level of injury, and injury severity. Hyperglycemia was the most common complication and was present in all patients in both the treatment and control groups. The overall infection rate was 64% in the control group compared with 26% in the treatment (P<0.05). The control group demonstrated a significantly increased rate of respiratory tract infections [45% control vs. 9% treatment (P<0.05)]. No surgical patients developed a wound infection. One treatment group patient experienced a GI bleed. CONCLUSIONS: This is the largest study evaluating the complications associated with high-dose steroid administration for spinal trauma in a pediatric population. Hyperglycemia was found in all spinal cord injury patients, regardless of steroid treatment. Paradoxically, infection rates were noted to be higher in the control group. GI and wound problems were not significantly different. Larger, multicenter prospective studies are needed to better understand the risks in pediatric SCI patients.

Neurological and vascular injury associated with supracondylar humerus fractures and ipsilateral forearm fractures in children.

BACKGROUND: Approximately 5% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, often referred to as a floating elbow when both injuries are displaced. Historically, these patients have higher complication rates than patients with an isolated supracondylar humerus fracture. The purpose of this study was to review the acute neurologic and vascular injuries in patients with ipsilateral, operative supracondylar humerus and forearm fractures and compare the findings with a cohort of isolated, operative supracondylar humerus fractures. METHODS: We performed an IRB-approved, retrospective review of all pediatric patients with ipsilateral, operative supracondylar humerus and forearm fractures from a single institution and compared our findings to a cohort of isolated, operative supracondylar humerus fractures. RESULTS: A total of 150 patients with operative supracondylar humerus and ipsilateral forearm fractures were compared with 1228 patients with isolated, operative supracondylar humerus fractures. Twenty-two of the 150 (14.7%) floating elbow patients had documented pretreatment nerve palsies compared with 96/1228 (7.8%) of isolated injury patients (P=0.006). Eighteen of 22 nerve palsies were in patients with forearm fractures that required reduction. The overall incidence of nerve palsy was 18.9% (18/95) when a forearm fracture required reduction compared with only 7.3% (4/55) in a forearm fracture that was not reduced (P=0.05). We did not find a significant difference in the rate of pulseless extremities when comparing the ipsilateral (6/150 4%) and isolated (50/1228 4.1%) injury patients. No compartment syndromes were identified in any patient with an ipsilateral injury. CONCLUSIONS: The rate of acute neurologic injury in ipsilateral supracondylar humerus and forearm fractures is almost twice than that found in patients with isolated supracondylar humerus fractures. This rate increases further when the forearm fracture requires a manipulative reduction. The likelihood of a pulseless extremity was not dependent upon the presence of a forearm injury in our study. The presence of an ipsilateral forearm fracture should alert the surgeon to carefully assess the preoperative neurovascular status of patients with supracondylar humerus injuries. LEVEL OF EVIDENCE: Level III.

Characteristics of spinal injuries secondary to nonaccidental trauma.

BACKGROUND: Nonaccidental trauma (NAT) is considered an uncommon cause of spine trauma in the pediatric population. Little has been published on such injuries and no large series is available in the literature. The purpose of this study is to describe the incidence and characteristics of spine trauma secondary to NAT. METHODS: An IRB-approved retrospective review of all patients presenting to a single level 1 pediatric trauma center with a spinal injury between 2003 and 2011 was performed. Patients were identified using our institution's trauma registry. Medical records were reviewed to identify all spine injuries that occurred as a result of NAT. These cases were reviewed for details regarding injury mechanism, type and location of injury, associated injuries, and the treatment. Our institution's NAT database was also queried to identify the total number of patients formally determined to have sustained any injury as a result of NAT during the same period. RESULTS: NAT was the cause of 11/342 (3.2%) spine injuries diagnosed during the study period. A total of 726 cases of NAT were identified, with spine injury present in 1.5%. All patients with spine trauma secondary to NAT were under the age of 2 years with an average age of 7 months. Among patients below 2 years with spinal trauma, NAT was tied as the most common mechanism, resulting in 38% of injuries. Eight of the 11 patients' spine injuries were cervical and 7 of these injuries were in the atlanto-occipital and atlantoaxial regions. Multilevel spine trauma was present in 64% of patients. Associated head and thoracic trauma was present in 73% and 36% of patients, respectively. Neurological injury was found in 54% of patients. The majority of injuries were treated nonoperatively and 1 patient required surgical management. CONCLUSIONS: NAT represents a very common yet often overlooked cause of spinal trauma in children under the age of 2 years. Because of its frequency in this age group, clinicians should consider including an assessment of the spine in all young NAT patients. Patients with spinal trauma sustained as a result of NAT must undergo a thorough evaluation for associated injuries remote to the spine, neurological deficit, and multilevel spine injury. SUMMARY: NAT is a common mechanism of spinal injury in patients below 2 years of age.

Segmental metadiaphyseal humeral bone loss in pediatric trauma patients: a case series.

BACKGROUND: The management of posttraumatic bone loss is complicated and often requires complex reconstructive procedures. No options exist that are specific to the treatment of the growing skeleton that has intercalary bone loss. We have observed reconstitution of the humerus in 2 cases that have precluded extensive management. METHODS: Two pediatric patients sustained traumatic injuries to the upper extremities, including humeral bone loss, and are presented after spontaneous reconstitution of the segmental bone loss. RESULTS: With treatment restricted to soft-tissue injury and bone stabilization with external fixation, both patients demonstrated radiographic healing of humeral segmental bone loss. Both patients were thought to have a partially intact periosteal sleeve. They have returned to sporting activities with mild loss of function. CONCLUSIONS: In certain pediatric injuries, spontaneous healing of segmental bone defects can occur. This response may obviate the need for complex, interventional procedures. LEVELS OF EVIDENCE: Level IV-case series.

Spine trauma in very young children: a retrospective study of 206 patients presenting to a level 1 pediatric trauma center.

BACKGROUND: The immature spine has anatomic and biomechanical properties that differ from the adult spine and result in unique characteristics of pediatric spinal trauma. Although distinct patterns of spinal injury have been identified in children younger than 10 years of age, little research has explored the differing characteristics of spinal trauma within this age group, particularly in the very young. The purpose of this study is to identify differences in the epidemiology and characteristics of spinal trauma between children under the age of 4 years and those between 4 and 9 years of age. METHODS: A review of all patients treated for spinal injury at a single large level I pediatric trauma center between 2003 and 2011 was conducted. Demographic data, injury mechanism, neurologic status, and details of any associated injuries were compiled. Radiographic studies were used to determine injury location and fracture classification. The patient population was divided into 2 groups: the infantile/toddler (IT) group (ages 0 to 3 y) and the young (Y) group (ages 4 to 9 y). Data were compared between these groups using the χ2 test and the Student t test to identify differences in injury characteristics. RESULTS: A total of 206 patients were identified. Fifty-seven patients were between 0 and 3 years of age and 149 were between 4 and 9 years old. Although motor vehicle collision was the most common cause of injury in both the groups, nonaccidental trauma was responsible for 19% of spine trauma among patients aged 0 to 3 years. Cervical spine injuries were much more common in the youngest patients (P<0.05) with injuries primarily in the upper cervical spine. Children in the IT group were more likely to sustain ligamentous injuries, whereas Y patients had more compression fractures (P<0.05). Neurologic injury was common in both the groups with IT patients more often presenting with complete loss of function or hemiplegia and Y patients sustaining more spinal cord injuries (P<0.05). IT patients had a 25% mortality rate, which was significantly higher than that of the Y group (P=0.005). CONCLUSIONS: This study shows many significant differences in characteristics of spinal injury in infants/toddlers when compared with older children. These differences can help guide diagnostic evaluation and initial management, as well as future prevention efforts. LEVEL OF EVIDENCE: Level III.