Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports.

BACKGROUND: Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. METHODS: Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. RESULTS: A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. CONCLUSIONS: The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Management of Fasciotomy Incisions After Acute Compartment Syndrome: Is Delayed Primary Closure More Feasible in Children Compared With Adults?

BACKGROUND: Recent adult literature has demonstrated that in the setting of acute compartment syndrome (ACS), if fasciotomy wounds are not closed after the first debridement, they are unlikely to be closed via delayed primary closure (DPC). The purpose of this study was to report the success of DPC through serial debridement in children with fasciotomy wounds secondary to ACS and to determine whether length of hospital stay is negatively affected by adopting a DPC strategy. METHODS: We identified all patients treated with fasciotomy for ACS (aged 0 to18 y). Patient, injury, and treatment characteristics were summarized by fasciotomy treatment type. Patients were grouped as: primary closure, DPC, and flap or skin graft (F/SG). For patients who required additional debridements after initial fasciotomy, treatment success was defined as closure by DPC (without requiring F/SG). Multivariable logistic regression was used to determine factors associated with additional surgeries, complications, and treatment success. RESULTS: A total of 82 children underwent fasciotomies for ACS. Fifteen (18%) patients were treated with primary closure at the time of their initial fasciotomy and were excluded from the remainder of the analysis, 48 (59%) patients underwent DPC, and 19 (23%) patients were treated with F/SG. The majority of delayed fasciotomy wounds were successfully closed by DPC (48/67, 72%) and the rate of successful closure remained consistent with each successive operative debridement. There were no differences across DPC and F/SG groups with respect to age, method of injury, or injury severity. Patients who underwent F/SG remained in the hospital for an average of 12 days compared with 8 days for those who underwent DPC (P<0.001). CONCLUSIONS: In the setting of ACS, pediatric fasciotomy wounds that are not closed after the first postfasciotomy debridement still have a high likelihood of being closed through DPC with serial surgical debridement. In children, persisting with DPC strategy for fasciotomy closure after ACS is more successful than it is in adults. LEVEL OF EVIDENCE: Level III.

Management of Gustilo-Anderson Type II and IIIA Open Long Bone Fractures in Children: Which Wounds Require a Second Washout?

INTRODUCTION: Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC. PATIENTS AND METHODS: At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range: 3.6 to 25.3 mo). All patients were followed-up at least until bony union. RESULTS: Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC. CONCLUSION: The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC. LEVEL OF EVIDENCE: Level IV-therapeutic, case cohort study.

Prevalence of Cozen's Phenomenon of the Proximal Tibia.

BACKGROUND: There has been little investigation into the epidemiology of Cozen's phenomenon, genu valgum as a complication of proximal tibial metaphysis fractures. In this study, we present a large case series of proximal tibia fractures in children to describe the prevalence, epidemiology, and characteristics associated with Cozen's phenomenon following proximal tibial fracture in children. METHODS: We searched the orthopedic database at our institution for all patients aged 1 to 8 years old with proximal tibia fractures presenting for initial fracture management between January 1, 2014 and December 31, 2017. Demographic data, mechanism of injury, fracture characteristics, and the presence of a concurrent fibula fracture were determined from the medical records. Initial and follow-up valgus angulation was measured as the angle between a line perpendicular to the proximal tibial physis and a line drawn along the axis of the tibia. Differences in the rate of valgus angulation by mechanism of injury and fracture type were compared. RESULTS: In total, 181 fractures in 181 patients were included in our study (98 male, 83 female). The average age at injury was 4.55 years (range, 1.02 to 7.95 y); 140 patients (77.3%, 140/181) had initial valgus angulation of <4 degrees; 20 of these patients (14.3%, 20/140) developed angulation of at least 4 degrees at some point during follow-up at an average of 0.8 months (range, 0.2 to 1.9 mo); 4 patients (20.0%, 4/20) with <4 degrees of initial angulation had persistent valgus angulation of 5 degrees at latest follow-up. Two of these patients were not scheduled to return because the provider did not determine the valgus angulation to be clinically meaningful. The 2 other patients were asymptomatic and continued to receive nonoperative management. No patients in our series required surgical correction of valgus deformity. CONCLUSIONS: Cozen's phenomenon is an uncommon complication of proximal tibial metaphysis fractures. Eliminating unnecessary radiographs and clinical visits for our pediatric trauma patients will improve the quality and value of care delivery. LEVEL OF EVIDENCE: Level IV.

Fracture Table Application for Pediatric Femur Fractures: Incidence and Risk Factors Associated With Adverse Outcomes.

BACKGROUND: Flexible elastic nails, submuscular plating, and rigid locked intramedullary nails are common methods of fixation for pediatric femur fractures (PFF) in which the fracture table is used to aid reduction. Little is known about complications associated with fracture table application in PFF. The purpose of this study was to determine the incidence and risk factors associated with adverse outcomes related to fracture table application for the treatment of PFF. METHODS: A retrospective chart review of all children (younger than 18 y) treated for a femur fracture with the use of the fracture table between 2004 and 2015 at a single tertiary pediatric hospital was performed. Data on demographics, mechanism of injury, treatment modality, radiographic characteristics, and fracture table-related complications were gathered. Complications of interest included nerve palsy, skin breakdown/ulceration, vascular injury, and compartment syndrome. Penalized likelihood logistic regression was used to determine risk factors associated with adverse outcomes. RESULTS: In total, 260 patients were included. There were 8 patients with nerve palsies related to positioning and traction on the fracture table (1 bilateral and 6 ipsilateral peroneal nerve palsies, 1 contralateral tibial nerve palsy; incidence of 3.1%). No other fracture table-related complications were recorded. Patients who developed a nerve palsy were significantly heavier (78.7 vs. 44.3 kg, P<0.001) and had a significantly longer mean surgical time (188.6 vs. 117.0 min, P<0.001). Multivariate analysis demonstrated weight to be the only significant risk factor for complications, with a 5% increase in odds of complication with each additional kilogram (odds ratio, 1.05; confidence interval, 1.03-1.08; P<0.001). CONCLUSIONS: Nerve palsy related to the use of the fracture table during the fixation of PFF occurred in 3.1% of patients in our series. Patients who developed nerve palsies were significantly heavier and had significantly longer surgical times. Although the use of the fracture table for fixation of PFF is safe, every effort should be made to minimize time in traction to avoid iatrogenic nerve palsy, particularly in heavier children (>80 kg). LEVEL OF EVIDENCE: Level III.

Validation of Patient-Reported Outcome Measurement Information System for Detection of Posttraumatic Stress in Children and Adolescents Following Procedures for Acute Orthopaedic Trauma.

OBJECTIVES: The efficiency and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were determined for pediatric orthopaedic trauma patients with posttraumatic stress disorder (PTSD) symptoms in a clinic setting. DESIGN: Prospective cohort study. SETTING: Single-institution, Level I trauma center. PATIENT SELECTION CRITERIA: All consecutive children aged 8-18 years undergoing procedures or surgery for orthopaedic trauma. OUTCOME MEASURES AND COMPARISONS: The convergent, divergent, and discriminant validity of the PROMIS Anger and Anxiety computerized adaptive tests (CATs) were evaluated and compared with the previously validated Child PTSD Symptom Scale (CPSS). The efficiency in time to completion of the outcome measures was compared between the CPSS and PROMIS surveys. Cutoffs for increased likelihood of PTSD were established for the PROMIS questionnaires. RESULTS: A total of 233 subjects were included in this study (mean age 13.1 years with SD 2.8 years, 71% male). The majority (51%) of injuries were related to sports, and most (60%) involved the upper extremity. Of those included, 41 patients had high levels of PTSD symptoms on the CPSS (18%; 95% CI, 13.1-23.2%). The CPSS took 182 (interquartile range [IQR] 141-228) seconds versus 52 (IQR 36-84) and 52 (IQR 36-70) seconds for PROMIS Anger and Anxiety CATs, respectively. Convergent validity showed patient scores on both PROMIS instruments significantly correlated with CPSS scores (Anger: P < 0.001, r = 0.51; Anxiety: P < 0.001, r = 0.41). Neither PROMIS score correlated with University of California Los Angeles Activity Score (Anger: r = -0.26; Anxiety: r = -0.22), a functional outcome measure, demonstrating divergent validity. Both PROMIS instruments sufficiently discriminated across PTSD risk groups (Anger P < 0.001; Anxiety P < 0.001). A score of at least 53 on PROMIS Anger or at least 48 on PROMIS Anxiety indicated an increased likelihood of PTSD risk. CONCLUSIONS: PROMIS Anger and Anxiety CATs are efficient and valid for evaluating posttraumatic stress in children following orthopaedic trauma procedures. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Incidence of Posttraumatic Stress Symptoms in Children.

OBJECTIVE: To determine the incidence of posttraumatic stress disorder (PTSD) symptoms and risk factors for their development in children and adolescents undergoing orthopaedic surgery for trauma. DESIGN: Prospective cohort study. SETTING: Level-1 trauma center. PATIENTS: Children (8 to 18), undergoing surgery for orthopaedic trauma. INTERVENTION: Upper and lower extremity surgery for orthopaedic trauma. MAIN OUTCOME MEASUREMENTS: PTSD symptoms at postoperative follow-up as determined by the Child PTSD Symptom Scale (CPSS). RESULTS: A total of 176 children with an average age at surgery of 13 years (8 to 18.8 years) participated in the study. Twenty-six subjects had high levels of PTSD symptoms (15%; 95% CI = 10.0 to 21.1%). Univariable and multivariable analyses determined that female sex (OR 2.63, 95% CI = 1.06 to 6.67, P = 0.04), older age at surgery (OR 1.25, 95% CI = 1.04 to 1.51, P = 0.02), and undergoing a previous surgery (OR 2.86, 95% CI = 1.06 to 7.73, P = 0.04) were all associated with increased PTSD risk. CONCLUSIONS: Children and adolescents experience a high level of PTSD symptoms (15%) after surgery for orthopaedic trauma. Clinicians should be aware of PTSD symptoms in children and adolescents after surgery for orthopaedic injuries and use comprehensive screening to facilitate timely intervention and treatment. LEVEL OF EVIDENCE: II.

Percutaneous leverage technique for reduction of radial neck fractures in children: technical tips.

PURPOSE: Paediatric radial neck fractures are challenging to treat. Multiple strategies exist for reduction and fixation; there is no clear consensus on the best surgical technique to achieve reduction. The percutaneous leverage technique is a method for reduction of radial neck fractures that has previously been described by Wallace, though there is a lack of published literature on this technique. We present a technical note and a modest case series on our modification to the percutaneous leverage technique accompanied by intramedullary fixation. METHODS: We describe a retrospective series of patients who underwent the modified percutaneous leverage technique for paediatric radial neck fracture reduction followed by flexible intramedullary nail fixation at a single Level I trauma centre from 2008 to 2016. This technique involves making a small incision over the dorsal border of the ulna and using a blunt curved surgical forceps to dissect towards the ulnar border of the radius just distal to the radial neck fracture site. The curved forceps is then used to push the radial shaft away from the ulnar shaft which reduces the radial neck fracture. Intramedullary fixation is then utilized to stabilize the reduction. Pre- and postoperative radiographs and clinical data from the medical record were reviewed, and patient, injury and treatment characteristics as well as complication rates are summarized. RESULTS: We successfully treated a series of eight radial neck fractures with the modified percutaneous leverage technique. This technique allows for a small incision and a minimally invasive method for the reduction of paediatric radial neck fractures. This allowed for subsequent intramedullary fixation and early postoperative elbow mobilization. In our series, no patients developed synostoses or sustained peripheral nerve injuries using this technique. CONCLUSION: The modified percutaneous leverage technique followed by intramedullary fixation is a safe and effective technique for fixation of displaced paediatric radial neck fractures. LEVEL OF EVIDENCE: Level IV.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

The AOSpine thoracolumbar spine injury classification system: A comparative study with the thoracolumbar injury classification system and severity score in children.

BACKGROUND: There is no uniform classification in the pediatric population for thoracolumbar (TL) fractures, nor any operative guidelines. This study evaluates the AOSpine TL spine injury classification in the pediatric population and compares it to the thoracolumbar injury classification system (TLICS), which has previously been validated in pediatric spine trauma. METHODS: Twenty-eight patients with operative TL injuries were identified from 2006 to 2016. Inclusion criteria included available imaging, operative records, age <18, and posterior approach. Each case was classified by AOSpine TL spine injury classification and TLICS. Each classification was compared to documented intraoperative posterior ligamentous complex (PLC) integrity as well as each other. RESULTS: Utilizing the AOSpine TL spine injury classification, 7 patients had type A injuries, 15 patients had type B injuries, and 6 patients had type C injuries; 21 patients had injuries classified as involving the PLC. Using TLICS, 16 patients had burst fractures, 6 patients had distraction injuries, and 6 patients had translation injuries; 21 patients had injuries classified as involving the PLC. Spearman correlation analysis substantiated convergence of AOSpine TL spine injury classification scores to TLICS scores (r = 0.75; 95% confidence interval, CI = 0.51 to 0.98; P < .001). Concordance between PLC integrity by each classification and intraoperative evaluation was 96% (27/28) of cases (k = 0.91; 95% CI = 0.73 to 1.08). Neurologic status was 100% concordant between the AOSpine TL spine injury classification and TLICS. CONCLUSION: There is high statistical correlation between the AOSpine TL spine injury classification and TLICS, and to intraoperative evaluation of the PLC, suggesting that the AOSpine TL spine injury classification is applicable to the pediatric population. LEVEL OF EVIDENCE: III.