Controlled Ankle Movement (CAM) Boot Provides Improved Outcomes With Lower Complications Than Short Leg Walking Cast in Low-energy Pediatric Lateral Ankle Injuries: A Prospective, Randomized Study.

BACKGROUND: Low-energy lateral ankle injuries (Salter-Harris 1 distal fibula, distal fibula avulsion fractures, and radiograph-negative lateral ankle injuries) are common in pediatric patients. Patient-based outcomes for the 2 treatment options, short leg walking cast (CAST) and controlled ankle motion (CAM) boot, are unknown. This study aims to determine differences between 2 treatments of low-energy lateral ankle injuries in pediatric patients. METHODS: A prospective, randomized controlled trial comparing the acute outcomes of CAST and CAM treatment for low-energy lateral ankle injuries in pediatric patients was completed. Patients were evaluated in-person at presentation and 4 weeks for ankle range of motion and Oxford foot and ankle score. A novel survey defining patient and parent satisfaction and time away from school/work was also completed. Treatment complications were documented. Patients were called at 8 weeks postinjury to determine other complications and the final time of return to sport. Mixed effects linear regression models evaluated change over time between the 2 treatment groups. RESULTS: After 60 patients were enrolled, 28 patients in the CAST group and 27 patients in the CAM group completed the study. Males comprised 51% (28), with 38 (69%) patients identifying as Hispanic. The patient's average age was 11.3±2.9 years and the average body mass index was 23.At the 4-week evaluation, the CAM group had improved range of motion, higher satisfaction scores (5.26 CAM vs. 4.25 CAST, P <0.05), similar pain scores (0.32 CAST vs. 0.41 CAM, P =0.75), and lower complications (0.54/patient CAST vs. 0.04/patient CAM, P <0.0001) than the CAST group. Female patients had improved inversion with CAM treatment than males ( P <0.05). Patients over age 12 in the CAST group had significantly decreased plantarflexion at week 4 ( P =0.002). Improvement in Oxford scores was similar between the CAST and CAM groups between the initial presentation and 4 weeks, except for increased improvement in CAM group Oxford scores for difficulty running and symptoms with walking/walking. At the 8-week evaluation, patients in the CAST group had a higher rate of continued symptoms than the CAM group (15.4% vs. 0%). CONCLUSIONS: CAM boot treatment of low-energy lateral ankle injuries in pediatric patients results in improved results and lower complications than CAST treatment. LEVEL OF EVIDENCE: Level I -randomized, controlled trial with a statistically significant difference.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. METHODS: A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. RESULTS: Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. CONCLUSIONS: Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. LEVEL OF EVIDENCE: Level V.

Trochlear Morphology Development: Study of Normal Pediatric Knee MRIs.

INTRODUCTION: Trochlear dysplasia is a known risk factor for patellar dislocations yet normal trochlea development is not well described. This study will define the articular cartilage (AC) and subchondral trochlear morphology development in pediatric patients using magnetic resonance imaging (MRI) evaluation. METHODS: A retrospective knee MRI review included patients aged 3 to 16 years with nonpatellofemoral-related diagnoses. International classification of diseases-9/International classification of diseases-10 codes were used to identify eligible study patients. Measurements of the trochlea were made on the basis of previously established methods using the axial MRI just distal to the physis at the deepest portion of the trochlear groove. Three linear [lateral trochlear height (LTH), medial trochlear height (MTH), and central trochlear height (CTH)] and 3 angular [sulcus angle (SA), lateral trochlear slope (LTS), and medial trochlear slope (MTS)] were made at AC and subchondral bone (SCB). The 12 measurements were made independently by 2 study authors. Inter-rater reliability was assessed using an interclass correlation coefficient for absolute agreement to the average of the scores. Trochlea measurements were summarized across age quartiles defined as first quartile (age, 5.1 to 8.3 y), second quartile (8.3 to 11.5 y), third quartile (11.5 to 14.3 y), fourth quartile (14.3to 16.9 y). Associations between age and trochlea measures were assessed using linear regression with Huber-White-adjusted SEs to account for clustering from a small number of patients (N=16) with >1 MRI. RESULTS: In total, 246 knee MRIs from 230 patients were included in this study; 113 patients (51%) were female, whereas 117 (49%) were male. A total of 116 MRIs (47%) were of the left knee and 130 (53%) were right knee. The average patient age was 11.4±3.4 years. Inter-rater agreement was high across all measures with interclass correlation coefficient values >0.7. Mean values for measurements are presented by age quartiles. LTH, MTH, and CTH showed a linear increase with age (range, 2 to 2.6 cm/y; P<0.001). SA, LTS, MTS measured at AC showed no change with age (P>0.05); however, LTS and MTS measured at SCB showed significant increases with age (0.6 and 0.9 degrees/y; P<0.001), whereas SA showed a decrease with age (-1.4 degrees/y; P<0.001). There were no significant differences found in the age associations by laterality, left versus right. There were no sex differences in the age associations for SA, LTS (P>0.05); however, for MTH, LTH, and CTH, males were found to have a significantly greater growth rate (P<0.001). CONCLUSIONS: This study found an increase in AC and SCB MTH, LTH, and CTH over time, as well as an increase in SCB LTS and MTS, with a decrease in SA. However, AC of the LTS and SA remained constant, with no significant change throughout growth. This normative data indicate that the LTS and SA of AC are predictors of final trochlea shape in normal development. Final trochlear morphologic development is nearly complete around age 12 years, with no significant changes occurring thereafter.

What Is New in Pediatric Bone Health.

BACKGROUND: This review paper aims to report on the last 5 years of relevant research on pediatric bone health in regard to nutrition and obesity, ethnic disparities, common orthopaedic conditions, trauma, spine, and sports medicine. METHODS: A search of the PubMed database was completed using the following terms: bone health, Vitamin D, pediatric, adolescent, sports medicine, fractures, spine, scoliosis, race, ethnicity, obesity, Slipped Capital Femoral Epiphysis, Osteogenesis Imperfecta, Duchenne's Muscular Dystrophy, neuromuscular, and cancer. Resultant papers were reviewed by study authors and determined to be of quality and relevance for description in this review. Papers from January 1, 2015 to August 31, 2020 were included. RESULTS: A total of 85 papers were selected for review. General results include 7 key findings. (1) Obesity inhibits pediatric bone health with leptin playing a major role in the process. (2) Socioeconomic and demographic disparities have shown to have a direct influence on bone health. (3) Vitamin D deficiency has been linked to an increased fracture risk and severity in children. (4) Formal vitamin D monitoring can aid with patient compliance with treatment. (5) Patients with chronic medical conditions are impacted by low vitamin D and need ongoing monitoring of their bone health to decrease their fracture risk. (6) Vitamin D deficiency in pediatrics has been correlated to low back pain, spondylolysis, and adolescent idiopathic scoliosis. Osteopenic patients with AIS have an increased risk of curve progression requiring surgery. Before spine fusion, preoperative screening for vitamin D deficiency may reduce complications of fractures, insufficient tissue repair, loosening hardware, and postoperative back pain. (7) Increasing youth sports participation has resulted in increased bone health related injuries. However, improved understanding of Relative Energy Deficiency in Sport effects on bone health has recently occurred. CONCLUSIONS: Increasing awareness of bone health issues in children will improve their recognition and treatment. Further research is needed on diagnosis, treatment, outcomes, and most importantly prevention of pediatric bone health diseases.

Nationwide Ethnic/Racial Differences in Surgical Treatment of Discoid Meniscus in Children: A PHIS Database Study.

BACKGROUND: Discoid meniscus, a congenital meniscus variant, may have greater incidence in Asian populations. No US population-based studies have examined the discoid meniscus ethnic/racial distribution. In pediatric patients undergoing meniscus surgery, it is hypothesized that ethnic/racial variability exists in patients with discoid meniscus and this variability is different than in patients with medial meniscus tears. METHODS: The Pediatric Health Information System was queried from 48 hospitals to examine patients 18 years of age and younger between 2015 and 2019, using International Classification of Diseases, 10th Revision, Clinical Modification codes. A cohort of patients treated surgically for discoid meniscus was compared with a cohort of patients treated surgically for medial meniscal tear. These 2 populations were compared based on age, sex, ethnicity/race, Current Procedural Terminology code, insurance, urban versus rural, and region of country. Univariate testing and multivariable logistic modeling were used to test for associations. RESULTS: A discoid meniscus cohort of 399 children (median age, 13.0 y) was compared with a medial meniscus tear cohort of 3157 children (median age, 16.0 y) (P<0.001). Hispanic/Latino children accounted for 36.8% of the discoid lateral meniscus and 22.7% of the medial meniscus populations (P<0.001). Among pediatric patients that had surgery for discoid lateral meniscus or medial meniscus, Hispanic/Latino children had 2.36 times the odds of surgery for discoid meniscus compared with White patients after adjusting for age and insurance (P<0.001). Asian children also had 2.41 times the odds of surgery for discoid meniscus compared with White patients (P=0.017). CONCLUSIONS: This study shows a significant association of ethnicity/race with discoid versus medial meniscus surgical treatment in children. Among pediatric patients undergoing surgery for discoid meniscus, Hispanic/Latino and Asian patients were a significantly larger percentage of the population than White patients. Hispanic/Latino children made up a greater percentage of the population having surgery for a torn discoid meniscus versus a torn medial mensicus. When evaluating pediatric patients, younger age and Asian or Hispanic/Latino ethnicity should increase attention to the possibility of a discoid meniscus. LEVEL OF EVIDENCE: Level IV.

Low Energy, Lateral Ankle Injuries in Pediatric and Adolescent Patients: A Systematic Review of Ankle Sprains and Nondisplaced Distal Fibula Fractures.

BACKGROUND: Lateral ankle injuries are one of the most common musculoskeletal injuries sustained by pediatric and adolescent athletes. These injuries can result in significant time lost from competition, affect performance when returning to play, and represent a significant burden on the health care system as a whole. The purpose of this study was to systematically review the literature on the diagnosis, treatment, and prevention of acute lateral ankle injuries and their chronic effects in pediatric and adolescent athletes (younger than 19 y). METHODS: This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines between September and December 2018. PubMed and Google Scholar were systematically searched using the search terms: ("distal fibula fracture" OR "ankle sprain") AND ("youth" OR "pediatric" OR "adolescent"). All authors participated in article review (N=172) for relevance and age restrictions in which 30 met the inclusion criteria. RESULTS: Thirty articles met inclusion criteria [Levels of Evidence I to IV (I: n=4, II: n=16, III: n=9, and IV: n=1)] including distal fibula fracture diagnosis and treatment, and risk factors, prevention, and chronic sequela of lateral ankle injuries in pediatric and adolescent patients. CONCLUSIONS: Low-energy, lateral ankle injuries are common in pediatric and adolescent patients, yet underrepresented in the medical literature. There is a lack of high-quality literature on diagnosis, treatment, and outcomes after Salter-Harris I distal fibula fractures. Available literature, however, suggests that there remains over diagnosis and over treatment of presumed Salter-Harris I distal fibula fractures. Adolescent ankle sprains dominate the available literature likely due to the high recurrence rate. Youth athletes and coaches should address risk factors and engage in injury prevention programs to prevent and minimize the effect of acute lateral ankle injuries. LEVELS OF EVIDENCE: Level III-Systematic review.

Delays in Obtaining Knee MRI in Pediatric Sports Medicine: Impact of Insurance Type.

BACKGROUND: Increased enrollment in government-based insurance plans has been reported. With youth sports injuries on the rise, increased ordering of advanced imaging such as magnetic resonance imaging (MRI) has occurred. This study sought to report on the impact of insurance type on access to and results of knee MRI in pediatric sports medicine patients. METHODS: A retrospective review of 178 consecutive pediatric sports medicine clinics was completed. INCLUSION CRITERIA: patients younger than 18 years, routine knee MRI ordered, sports medicine diagnosis, and insurance. Data included basic demographics, injury date, date and location (urgent care vs. clinic) of the first presentation, details of MRI ordering and approval, date and location of MRI follow-up, MRI results (negative, minor findings, major findings), and eventual treatment required. RESULTS: A total of 168 charts underwent a complete review. The patients' average age was 14±3 years and 54% (N=90) were female. Ninety-eight had government insurance and 70 had commercial insurance. The time between injury and MRI completion was significantly longer with government insurance (34 vs. 67 d, P<0.01). Government insurance had increased wait time between the first visit and MRI completion (11 vs. 40 d, P<0.001) as well as MRI order and completion (9 vs. 16.5 d, P<0.001). There was no significant difference in positive findings on MRI between insurance groups, including both major and minor findings nor in the proportion receiving eventual operative treatment. CONCLUSION: Pediatric sports medicine patients with government insurance have delays in obtaining knee MRI, despite there being no difference in the rate of positive findings and subsequent operative treatments. LEVEL OF EVIDENCE: Level III-case-control study.

Iliotibial band autograft: what size is the graft? A mathematical and cadaveric model : ITB single and double strand size.

BACKGROUND: The iliotibial band (ITB) is used in anterior cruciate ligament (ACL) reconstruction in skeletally immature patients as well as several other orthopedic reconstructions. The purpose of this study is to determine the size of the ITB as an autograft option in ACL reconstruction surgery or other orthopedic soft tissue reconstructions. METHODS: Five adult cadavers resulting in nine ITB were used. Thickness and width of the ITB were determined. Using ITB width of 15-60 mm, single and doubled graft sizes were determined using standard surgical graft size technique. Geometric calculations based on average graft thickness were used to mathematically confirm the graft size of the ITB. RESULTS: The ITB is less than 1 mm in thickness in males and females. Cadaveric measurements were less than 1 mm larger than mathematical measurements, in majority of measurements. ITB autograft can be harvested to a maximum 9 mm single-stranded graft or > 12 mm doubled graft. A minimum of 50 mm of ITB width is required to make a 8 mm graft. CONCLUSIONS: ITB is a versatile graft that can be used for a graft size up to 9 mm single strand and over 12 mm double strand. A minimum of 50 mm width of ITB is required to obtain a 8 mm-diameter autograft. To ensure appropriate graft size, surgeons should consider harvesting the maximum amount of ITB when performing ACL reconstructions in skeletally immature patients. CLINICAL RELEVANCE: Surgeons have a quick reference for the width of ITB they should harvest based on the size of graft they require for a successful surgery.

Hamstring Autograft Too Small: How Much Allograft Do You Need to Supplement to a Desired Hybrid Graft Size?

PURPOSE: To determine a simple rule for choosing supplemental allograft size for hybrid anterior cruciate ligament reconstruction using mathematical and cadaveric models. METHODS: Mathematical and cadaveric models were used to determine the rule. The mathematical model required application of the geometric Pythagorean theorem to add areas of circles. Cadaveric semitendinosus and gracilis tendons were combined in multiple quadrupled hamstring size combinations and then sized using standard surgical techniques to confirm the mathematical model. RESULTS: Geometric measurement, not simple addition, of graft diameters was required to determine the final graft size. Direct comparison of cadaveric and mathematical models showed close relations. If a final graft size of 7 mm is desired, an added diameter of all grafts of approximately 9.5 mm is needed. If a final graft size of 8 mm is desired, an added diameter of all grafts of approximately 11 mm is needed. If a final graft size of 9 mm is desired, an added diameter of all grafts of approximately 12.5 mm is needed. If a final graft size of 10 mm is desired, an added graft diameter of approximately 14 mm is needed. Cadaveric hamstring measurements were similar to the mathematical model. CONCLUSIONS: By use of mathematical and cadaveric models, simple rules for determining the additional size of allograft diameter needed to supplement undersized hamstring autograft were created. CLINICAL RELEVANCE: With the increasing availability of allograft types and sizes, surgeons currently have no guidelines on the size of allograft that is required to supplement an undersized hamstring autograft. Simple rules were created for determining the amount of allograft supplementation required for undersized hamstrings and are easily applied to clinical situations.

Defining a Safe Zone for All-Inside Lateral Meniscal Repairs in Pediatric Patients: A Magnetic Resonance Imaging Study.

PURPOSE: To establish a safe zone for all-inside meniscal fixation in pediatric patients by use of magnetic resonance imaging (MRI) measurements between the popliteal tendon (PT) and popliteal neurovascular bundle (PNVB). METHODS: Patients aged 5 to 16 years with normal or nearly normal knee MRI scans were included. They were grouped by age: group I, 5 to 7 years (n = 61); group II, 8 to 10 years (n = 59); group III, 11 to 13 years (n = 60); and group IV, 14 to 16 years (n = 70). At the level of the lateral meniscus, 2 lines starting at the lateral patellar tendon border and ending at the medial edge of the PT (D1) and the lateral edge of the PNVB (D2) were made on an axial knee MRI scan. A third line (D3) connected D1 to D2 at the meniscocapsular junction of the posterior horn of the lateral meniscus (PHLM). A fourth line (D4), derived geometrically, was parallel and 8 mm anterior to D3, simulating the anterior edge of the PHLM. RESULTS: Axial MRI scans of 250 pediatric patients (aged 5-16 years) were retrospectively reviewed. Analysis showed significant correlation between age and sex for D3 (P < .0001). For D3, there were significant differences among all age groups, except between groups III and IV. The average D3 by age group was 14.1 mm (standard deviation [SD], 3.1 mm) for group I, 15.8 mm (SD, 2.5 mm) for group II, 17.0 mm (SD, 3.3 mm) for group III, and 17.2 mm (SD, 3.1 mm) for group IV. The average D4 was 11.39 mm (SD, 2.6 mm), 13.24 mm (SD, 2.24 mm), 14.59 mm (SD, 2.89 mm), and 14.80 mm (SD, 2.79 mm), respectively. There were significant differences in D3 and D4 in male versus female patients (17.6 mm vs 15.7 mm, P < .001, and 14.9 mm vs 13.2 mm, P < .001, respectively), particularly in groups III and IV (17.0 mm vs 13.8 mm and 16.8 mm vs 13.9 mm, respectively). CONCLUSIONS: This study provides normative data of the distance between the PNVB and PT at the meniscocapsular junction (D3) and anterior edge of the PHLM (D4) with the knee in full extension. Combined with previous studies showing that the addition of knee flexion increases the distance between the meniscus and the neurovascular bundle, these data can be used by surgeons to improve the safety of PHLM repair in pediatric patients. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients.

What's New in Pediatric Medial Epicondyle Fractures?

BACKGROUND: Medial epicondyle fractures are predominantly seen in adolescent, male patients. Historically, nonoperative intervention was the mainstay of treatment. With increasing upper extremity demands of young athletes and reports of valgus instability after nonoperative treatment, there has been an increased interest in operative indications. Controversy regarding proper imaging and measurement of displacement complicates decision-making algorithms. Review of recent literature is required for improved decision making. METHODS: We searched the PubMed database for all papers related to the treatment of medial epicondyle fractures in patients under 18 years of age published between January 1, 2005 and March 15, 2016. This resulted in 39 papers written in English for review. Papers were included based upon subject matter and contribution of new findings to literature. Review articles were excluded. RESULTS: In total, 39 papers were reviewed and 30 were included in this review. Five classic manuscripts on medial epicondyle fractures in children provide appropriate historical and background information as needed. CONCLUSIONS: Medial epicondyle fractures represent a variety of low and high-energy mechanisms, displacement, treatment options, and complications. This paper reviews recent literature on these topics. Controversy regarding imaging modality, displacement measurement accuracy, and surgical indications still exist. Long term, patient based, functional outcome studies of operative versus nonoperative treatment are needed to improve our treatment algorithms of this injury. Treatment algorithms should be individualized to each specific patient and fracture. LEVEL OF EVIDENCE: Level 5.

What's New in Pediatric Upper Extremity Sports Injuries?

BACKGROUND: Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the most recent literature, highlighting updates on sports-related upper extremity injuries in pediatric patients. METHODS: An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric overhead athletes, osteochondritis dissecans (OCD) of the capitellum, medial epicondyle fractures, shoulder instability, and clavicle fractures. Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013 to May 30, 2017. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics. RESULTS: A total of 51 articles were deemed to have contributed significant findings to the literature: 11 overhead athlete, 9 OCD of the capitellum, 6 medial epicondyle fractures, 17 shoulder instability, and 8 clavicle fractures. The level of evidence for most studies was either Level III or IV. CONCLUSIONS: Overuse and traumatic conditions of the pediatric elbow including UCL tear, capitellar OCD, and medial epicondyle fractures represent a significant portion of injuries in the overhead athlete. Research in the prevention and treatment of primary and recurrent shoulder instability in young athletes continues to evolve. The operative treatment of clavicle fractures in adolescents has been increasing without a commensurate increase in the level of evidence supporting such treatment. Advances have been made in the treatment of sports-related upper extremity injuries in pediatric patients, however, high-level, comparative outcomes research in many areas is lacking and this review may help inform topics for future study. LEVEL OF EVIDENCE: Level IV-Literature review.

What's New in Pediatric Sports Conditions of the Knee?

BACKGROUND: Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the literature, highlighting recent updates on sports-related knee injuries in the pediatric athlete. We specifically examined literature on tibial spine fractures, osteochondritis dissecans (OCD) of the knee, and patellar instability. Because of the volume of literature on the subject, pediatric, and adolescent anterior cruciate ligament injuries were not included in this review. METHODS: An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric: tibial spine fractures, patellar instability, and osteochondritis dissecans (OCD). Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics. RESULTS: A total of 31 articles were deemed to have contributed significant findings to the literature: 5 tibial spine, 17 patellar instability, and 9 OCD. The level of evidence for most studies was either level III or IV. CONCLUSIONS: The optimal treatment for tibial spine fractures remains controversial. The evaluation of risk factors for recurrent patellar instability is important in determining the optimal treatment strategy following first-time patellar dislocation. Future multicenter studies on pediatric OCD have the potential to further understanding of this difficult problem. High-level, comparative outcomes research on a variety of pediatric sports related injuries is lacking and this review may help inform topics for future study. LEVEL OF EVIDENCE: Level IV-literature review.

Utility of Adult-Based Discoid Lateral Meniscus Diagnostic Criteria in a Pediatric Population.

Background: Commonly cited discoid lateral meniscus (DLM) imaging definitions are based on adult magnetic resonance imaging (MRI) measurements. This pathology commonly presents in pediatric populations; however, whether accepted adult measurements reliably apply to children and adolescents is unknown. Purpose/Hypothesis: This purposes of the study were to determine (1) the utility of applying adult-accepted MRI definitions of DLM to pediatric patients, (2) whether sex differences affect the applicability of the criteria, and (3) whether MRI magnet strength and/or tear presence affect MRI measurements for diagnosing DLM in pediatric patients. It was hypothesized that MRI criteria for DLM would be similar in adults and pediatric patients. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 consecutive MRIs from pediatric patients with DLM were evaluated, with 91 scans included. Two study authors independently reviewed the MRIs, evaluating meniscal height and width on sagittal and coronal images, "bow tie signs" on sagittal images, tibial sagittal and coronal width, and tear presence. For analysis, MRI magnet strength was dichotomized into high (>1.5 T) and low (<1.5 T) groups. Results: The mean age of the patients at MRI evaluation was 12.3 ± 3.4 years; 51% of the patients were male, and 56% of the scans were of left knees. Included patients with DLM showed a mean of 3.68 bow tie signs, a sagittal total anterior to posterior meniscal width/tibial width ratio of 73%, a coronal meniscal width/tibial width ratio of 30%, and a coronal, transverse width of the lateral meniscus at the midportion of the meniscal body of 20.6 ± 7.7 mm. The MRI tesla strength of the images included in this study ranged from 0.3 to 3. It was determined that high- versus low-resolution MRI scans did not affect the inter- or intraobserver reliability of the MRI measurments (P > .05). However, several measurements showed improved intraclass correlation coefficients with increased tesla strength. Conclusion: This study confirms that pediatric patients with DLM, diagnosed by board-certified pediatric sports medicine orthopaedic surgeons, have measurements on MRI consistent with adult DLM diagnostic criteria. This finding held true regardless of sex or MRI tesla strength. Pediatric patients with DLM had >3 bow tie signs, >70% sagittal tibial plateau coverage, >14 mm coronal width, and >20% coronal tibial plateau coverage on MRI.

First Rib Stress Fracture in an Adolescent Elite Tennis Player: A Case Report.

CASE: A 16-year-old, right-hand-dominant, Asian male, elite tennis player presented to the clinic with a 1-month history of left shoulder pain. Originally, the pathology was believed to be shoulder-based, but lack of improvement after several weeks of therapy warranted further imaging, which ultimately revealed a nondisplaced fracture of the posterior left first rib. CONCLUSION: Stress injuries are not uncommon in the sport of tennis, but atraumatic rib fractures are rare. Given the increase in youth sports specialization and overtraining and other risk factors such as adolescent age and race, it is important to keep rib stress fracture on the differential.

Reliability of MRI Interpretation of Discoid Lateral Meniscus: A Multicenter Study.

Background: Discoid lateral meniscus (DLM) has a varied and complex morphology that can be challenging to assess and treat. Preoperative magnetic resonance imaging (MRI) is frequently used for diagnosis and surgical planning; however, it is not known whether surgeons are reliable and accurate in their interpretation of MRI findings when defining the pathomorphology of DLM. Hypothesis: Surgeons experienced in treating DLM are able to reliably interpret DLM pathology using MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Knee MRI scans from 44 patients (45 knees) were selected from a pool of surgically treated patients with DLM. Five reviewers (fellowship-trained pediatric sports medicine surgeons) performed independent review of each MRI scan using the PRiSM Discoid Meniscus Classification. Inter- and intraobserver reliability of the rating factors-primary (width, height, presence of peripheral instability or tear) and secondary (location of instability or tear, tear type)-was assessed using the Fleiss κ coefficient, designed for multiple readers with nominal variables (fair reliability, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). Reliability is reported as κ (95% CI). Results: Interobserver reliability in assessing most primary and secondary characteristics ranged from substantial (meniscal width) to moderate (peripheral instability, anterior instability, posterior instability, and posterior tear). Intraobserver reliability for most characteristics ranged from substantial (peripheral instability, presence of tear, anterior instability, posterior instability, and posterior tear) to moderate (meniscal width, anterior tear, and tear type). Notable exceptions were presence of tear, anterior tear, and tear type-all with fair interobserver reliability. Height had poor interobserver reliability and fair intraobserver reliability. Conclusion: Orthopaedic surgeons reliably interpret MRI scans using the PRiSM Discoid Meniscus Classification for the majority of DLM characteristics but vary in their assessment of height and presence and type of tear. MRI evaluation may be helpful to diagnose discoid by width and identify the presence of instability: 2 major factors in the decision to proceed with surgery. Arthroscopic evaluation should be used in conjunction with MRI findings for complete DLM diagnosis.

Comprehensive Arthroscopic Characterization of Discoid Meniscus Tears and Instability Using the PRiSM Discoid Meniscus Classification.

The discoid meniscus is a congenital abnormality, with the vast majority occurring in the lateral meniscus. More commonly seen in pediatric populations, patients present with acute or chronic knee symptoms such as joint line pain, audible or palpable mechanical symptoms, and the inability to achieve terminal extension. The classic discoid classification system by Watanabe excludes anterior and horizontal instability and tearing that commonly occur with this pathology. A comprehensive classification, the Pediatric Research in Sports Medicine (PRiSM) Discoid Meniscus Classification, was developed to include these characteristics. To complement this classification system, we describe a complete arthroscopic examination of the discoid meniscus, assessing meniscal width, height, instability, and tearing. For thorough anterior assessment, the importance of medial portal viewing with lateral portal probing is highlighted. Assessment of the meniscus for tearing and instability should be performed before and after saucerization. Consistent use of a comprehensive classification system and a diagnostic arthroscopic exam will improve the understanding, treatment, and quality of research in the discoid meniscus.

Treatment Variability and Complications Associated With Pediatric Lateral Ankle Injuries: A POSNA Quality, Safety, and Value Initiative Survey.

Background: Isolated pediatric lateral ankle injuries, including ankle sprain (AS) and nondisplaced Salter-Harris type 1 (SH-1) distal fibular fracture, are common orthopaedic sports-related injuries. Variability in treatment is suspected among pediatric orthopaedic surgeons. Complications from medical treatment or lack thereof have not been reported in this population. Purpose: The purpose of this study was to investigate treatment variability and associated complications after pediatric AS and SH-1 via a survey of members of the Pediatric Orthopaedic Society of North American (POSNA). Study Design: Cross-sectional study. Level of evidence, 5. Methods: A voluntary, anonymous survey was distributed to POSNA membership (approximately 1400 members) via email. Survey questions, specific to both grade 1 or 2 AS and nondisplaced or minimally displaced SH-1 injuries in skeletally immature patients, focused on initial evaluation, immobilization, return to sports, and complications. We analyzed variability both in treatment between AS and SH-1 injury and in respondent characteristics. For statistical analysis, chi-square or Fisher exact test was used for categorical variables, and analysis of variance was used for continuous variables. Results: The survey response rate was 16.4% (229/1400). Of the respondents, 27.7% used examination only to distinguish between AS and SH-1, whereas 18.7% performed serial radiography to aid with diagnosis. A controlled ankle motion boot or walking boot was the most common immobilization technique for both AS (46.3%) and SH-1 (55.6%); the second most common technique was bracing in AS (33.5%) and casting in SH-1 (34.7%). Approximately one-third of all respondents recommended either outpatient or home physical therapy for AS, whereas only 11.4% recommended physical therapy for SH-1 (P < .01). Results showed that 81.2% of respondents reported no complications for SH-1 treatment and 87.8% reported no complications for AS treatment. Cast complications were reported by 9.6% for SH-1 and 5.2% for AS. Rare SH-1 complications included distal fibular growth arrest, infection, nonunion, late fracture displacement, and recurrent fracture. Conclusion: Significant variability was found in primary treatment of pediatric AS and SH-1 injuries. Rare complications from injury, treatment, and neglected treatment after SH-1 and AS were reported.

Clinical and Radiographic Differentiation of Pediatric Patellar Sleeve Fractures and Other Inferior Pole Pathologies.

BACKGROUND: Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larsen-Johansson syndrome (SLJS). PURPOSE: The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF, and SLJS. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Retrospective review of skeletally immature patients diagnosed with PSF, IPF, and SLJS between 2011 and 2019 at a single urban academic center was performed. Chart and radiographic review was completed. Between-group differences were assessed using analysis of variance, Kruskal-Wallis test, and Fisher exact test, as appropriate to variable distributions. RESULTS: In total, 125 patients (82% male) were included, with a mean (SD) age of 10.7 (2) years (16 PSF, 51 IPF, 58 SLJS). There were no significant differences in patient characteristics between the 3 groups. One hundred percent of the patients with PSF (P < .001) and IPF (P < .001) had acute trauma, compared with 24% of patients with SLJS. Fewer patients with PSF had an intact straight leg raise (38%) compared with those with IPF (94%; P < .001) and SLJS (98%; P < .001). Fewer patients with SLJS had knee swelling (41%) compared with those with PSF (93%; P < .001) and IPF (94%; P < .001). More patients with PSF had knee effusion (81%) compared with those with IPF (37%; P = 0.011) and SLJS (3%; P < .001). More patients with SLJS were able to bear weight (88%) compared with those with IPF (12%; P < .001) and PSF (0; P < .001). Radiographically, compared with those with IPF and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 [P < .001] and 6.5 [P < .001] vs 12.9 mm), intra-articular effusion (6.1 [P = .014] and 4.9 [P = .001] vs 9.2 mm), maximum fragment size (26 [P = .004] and 17.7 [P < .001] vs 45.3 mm), and maximum fragment displacement (1.24 [P = .002] and 1.45 [P = .003] vs 13.30 mm), respectively. Compared with those with SLJS (1.10), patients with PSF (1.92; P < .001) and IPF (1.22; P < .001) had patella alta with higher mean Insall-Salvati ratios >1.2. CONCLUSION: Differences in clinical features such as ability to straight leg raise, knee swelling, knee effusion, ability to bear weight, and radiographic features, such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location, and patellar height, can all be helpful in recognizing rare pediatric inferior patellar pathology, thus increasing efficiency in indicating for higher-level imaging to reach a prompt diagnosis and provide appropriate treatment.

Arthroscopic Treatment of Symptomatic Discoid Lateral Meniscus and Nondiscoid Meniscus in Adolescent Patients.

BACKGROUND: Discoid lateral meniscus (DLM) is a rare condition. Patient-reported outcomes using validated instruments are underreported in the literature. DLM outcomes have not been directly compared with nondiscoid meniscus (non-DLM) in adolescent patients. PURPOSE/HYPOTHESIS: This study sought to analyze the difference in patient characteristics, surgical treatment, and patient-reported outcomes for adolescent patients arthroscopically treated for symptomatic DLM and non-DLM pathology. We hypothesized that DLM and non-DLM patient-reported outcomes would be similar. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of patients aged <18 years with symptomatic DLM and non-DLM pathology was completed between 2015 and 2021 at a single academic institution. Chart reviews for patient characteristics and surgical operative indications and technique were completed. Patient-reported outcome scores were prospectively collected preoperatively and at 6 months, 1 year, and 2 years after surgery. RESULTS: Patients in the DLM group (n = 48), when compared with the non-DLM group (n = 45), were younger (12.71 vs 15.78 years, respectively; P < .001) and had lower body mass index (24.53 vs 28.91, respectively; P < .02). Both groups were majority Hispanic and more commonly male (DLM 65% vs non-DLM 60%). All of the DLM patients had surgery on the lateral discoid meniscus (n = 48), whereas the non-DLM group had surgery on the lateral meniscus (n = 37), medial meniscus (n = 7), or both (n = 1). A majority of patients in both groups underwent meniscal repair (DLM 73% and non-DLM 62%), and there was no difference in surgical treatment between groups (P > .05). A statistically significant improvement was seen in International Knee Documentation Committee (IKDC) and Physical Activity Questionnaire (PAQ) scores from the preoperative assessment to 6 months, 1 year, and 2 years after surgery for both DLM and non-DLM groups (P < .05). No difference was found in scores between DLM and non-DLM groups, between sexes, or between age groups (<13 years or ≥13 years) (P > .05). CONCLUSION: Although patients with DLM were younger and had lower body mass index, the IKDC and PAQ scores were not significantly different between the DLM and non-DLM groups. Both groups showed a significant improvement in scores relative to their preoperative scores. Sex and age did not affect IKDC or PAQ scores.