Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures.

BACKGROUND: Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT. METHODS: All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated. RESULTS: Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT (P<0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed. CONCLUSIONS: In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture. LEVEL OF EVIDENCE: Level III-diagnostic study.

The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability.

BACKGROUND: The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS: We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS: The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION: Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE: Retrospective Study, Level III.

Relationship Between Sever Disease and Skeletal Maturity.

BACKGROUND: Sever disease is a common condition in active, growing children. This condition presents as pain in the heel and is thought to be an overuse condition of the calcaneal apophysis. There are currently no defined radiographic diagnostic criteria for evaluation of Sever disease, with radiographs generally showing normal appearance of the calcaneal apophysis. A better understanding of the relationship of Sever disease and skeletal maturity may allow for improved interpretation of radiographs when trying to diagnose this condition. METHODS: ICD-9 code 732.5 was used to search for patients diagnosed with Sever disease from 2007 to 2015 at a single hospital. For every patient with Sever disease with available calcaneal imaging within 40 days of diagnosis, heel x-rays were staged for calcaneal maturity score using a previously described calcaneal skeletal maturity assessment system. Controls matched by age, race, and sex were evaluated for calcaneal stage to compare with the Sever patients. RESULTS: The chart review yielded 78 patients diagnosed with Sever disease by the orthopaedic attending, 39 of which have x-rays around the time of diagnosis. Calcaneal scores averaged 2.2±0.8 for all patients, 2.1±0.9 for male individuals, and 2.3±0.8 for female individuals. The average age for male individuals was 10.4±1.9 years and for female individuals, 9.2±2.2 years. The ages of diagnosis were similar for patients with and without x-rays. Twenty-two of 39 patients with Sever disease were calcaneal stage 2, and 37 of 39 were stages 1, 2, or 3. We calculated the absolute difference from stage 2 for the Sever and control groups. Mean difference from stage 2 was 0.51±0.68 for the Sever patients and 0.95±0.79 for control patients (P=0.01). CONCLUSION: Sever disease occurs in a very narrow range of skeletal maturity, as measured by the calcaneal skeletal maturity assessment system and our observations with chronological age. When compared with age-matched and race-matched controls, stage 2 was seen more frequently in the Sever patients. If a child is not within calcaneal stages 1, 2, or 3, then a different diagnosis should be considered. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Youth Baseball Coach Awareness of Pitch Count Guidelines and Overuse Throwing Injuries Remains Deficient.

BACKGROUND: Baseball is one of the most popular youth sporting activities. Youth pitchers remain at high risk for shoulder and elbow overuse injuries despite well-established recommendations on pitch count limits. The purpose of this investigation was to conduct surveys of youth baseball coaches evaluating the current state of understanding and compliance with youth pitch count guidelines and risk factors for overuse injuries. METHODS: A total of 82 youth baseball coaches in surrounding suburban areas outside 2 separate Midwestern metropolitan cities were asked to answer an anonymous 13-question survey. Survey questions solicited demographic information of youth athletes coached, while assessing for incidence, knowledge of, and compliance with established recommendations on pitch count limits and upper extremity overuse injuries in youth pitchers. RESULTS: In total, 61 of 82 (74%) coaches returned surveys. The majority of coaches reported coaching male athletes (89%, n=54) primarily between the ages of 11 to 12 years (51%, n=31). A total of 56% (n=34) of coaches reported "always" keeping track of pitch counts; however, 92% (n=56) reporting not keeping track of pitches based on established recommendations by the American Sports Medicine Institute, whereas 56% were noncompliant with age appropriate pitch count recommendations as established by the 2006 US Baseball Medical and Safety Advisory Committee. Only 13% (n=8) of coaches were able to correctly identify risk factors for overuse injuries while acknowledging the necessity of off-season strengthening. Thirty-eight percent (n=23) of coaches reported sitting out an athlete because of overuse injury, with the highest rates found in those coaching the youngest (≤8 and younger) and oldest (≥17 and older) age groups. Meanwhile, 15% (n=9) of coaches were noncompliant with age-based recommendations against throwing breaking pitches. CONCLUSIONS: Knowledge regarding pitch count guidelines established to prevent overuse injuries to the shoulder and elbow in youth pitchers remains deficient in the cohort of coaches surveyed. LEVEL OF EVIDENCE: Level IV-Case Series.

Early MRI Detection and Closed Bone Graft Epiphysiodesis May Alter the Course of Avascular Necrosis Following Unstable Slipped Capital Femoral Epiphysis.

BACKGROUND: Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). Early identification and surgical intervention for AVN may help preserve the femoral head. METHODS: We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. AVN was diagnosed based on 2 different postoperative protocols. Seventeen patients (17 hips) had a scheduled magnetic resonance imaging (MRI) between 1 and 6 months from initial surgery, and the remaining 31 patients (33 hips) were evaluated by plain radiographs alone. If AVN was diagnosed, we offered core decompression and closed bone graft epiphysiodesis (CBGE) to mitigate its affects. At final follow-up, we assessed progression of AVN using the Steinberg classification. RESULTS: Overall 13 hips (26%) with unstable SCFEs developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 mo). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 free vascularized fibula graft, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 mo) postoperatively. None of the 4 patients treated with CBGE within 2 months postoperatively progressed to stage IVC AVN. The 2 patients treated after 4 months postoperatively both progressed to stage VC AVN.Plain radiographs demonstrated AVN in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 mo). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the 1 treated with CBGE, progressed to stage IVC AVN or greater. CONCLUSIONS: Although all patients with positive MRI scans developed radiographic AVN, none of the 4 patients treated with CBGE within 2 months after pinning developed grade IVC or greater AVN. Early MRI detection and CBGE may mitigate the effects of AVN after SCFE. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Conservative Management of Minimally Displaced (≤2 mm) Fractures of the Lateral Humeral Condyle in Pediatric Patients: A Systematic Review.

BACKGROUND: Fractures to the lateral humeral condyle are common in the pediatric population and can lead to complications related to displacement of the fracture fragment. The ideal treatment for minimally displaced fractures (measuring ≤2 mm) is controversial. METHODS: A systematic review was performed identifying and evaluating studies related to displacement of lateral humeral condyle fractures in pediatric patients. Databases included in this review were PubMed, Biosis Preview, SPORTDiscus, PEDro, and EMBASE. We investigated the rate of subsequent displacement for minimally displaced fractures following immobilization, the time span in which fracture displacement occurs, and the complications related to displacement despite immobilization. RESULTS: Our review of the literature found 6 studies that matched the search criteria. The risk of subsequent displacement in minimally displaced fractures initially treated with immobilization was 14.9% with fracture displacement typically occurring within the first week following injury. Malunion, nonunion, and loss of motion were the most commonly identified complications following subsequent displacement. CONCLUSIONS: For minimally displaced fractures of the lateral humeral condyle, appropriate diagnosis of fracture stability and fracture displacement with close radiographic follow-up 1 week following injury dictate the success of conservative management. LEVEL OF EVIDENCE: Level II-systematic review of level-II or level-I studies with inconsistent results.

Outcomes of Nonoperative Pediatric Medial Humeral Epicondyle Fractures With and Without Associated Elbow Dislocation.

BACKGROUND: Medial epicondyle fractures may occur in isolation or with associated elbow dislocation. In the absence of open fracture or fragment incarceration, nonoperative management with immobilization has been shown to result in generally successfully outcomes comparable with those reported after surgical fixation. However, no comparative investigation has assessed outcomes after nonoperative treatment based on the presence or absence of elbow dislocation. METHODS: A systematic review was conducted investigating all studies in the literature reporting nonoperative outcomes for isolated medial epicondyle fractures and fracture-dislocations. Databases included in this review were PubMed, Biosis Preview, SPORTDiscus, PEDro, and EMBASE. We sought to evaluate results related to the incidence and outcomes of bony nonunion and the incidence of elbow stiffness, pain, ulnar neuropathy, cubitus valgus deformity, and laxity between isolated fractures of the medial epicondyle and fracture-dislocations. RESULTS: Review of the literature yielded 7 studied meeting appropriate inclusion and exclusion criteria, comprising 81 total patients (n=42 patients with fracture-dislocations, n=39 patients with isolated fracture). Bony nonunion occurred in 69% (n=29) of patients with fracture-dislocation versus 49% (n=19) with isolated fractures (P=0.11); however, both groups had minimal clinical or functional disabilities at final follow-up. Decreased elbow flexion and extension range of motion were significantly more frequent after fracture-dislocation than isolated fractures [43% (n=18) vs. 15% (n=6), respectively, P=0.01], while patients rarely demonstrated pain, ulnar neuropathy, or deformity in the presence or absence of dislocation. CONCLUSIONS: In the absence of absolute surgical indication, nonoperative management of isolated medical epicondyle fractures with or without concomitant elbow dislocation seems to be successful with few long-term complications leading to functional disability. However, increased rates of nonunion, elbow stiffness, and elbow laxity may occur with fracture-dislocations, and merit further study with validated functional outcome scores. Further comparative studies are necessary to determine the true indications and outcomes in nonoperatively managed medial epicondyle fractures. LEVEL OF EVIDENCE: Level II-systematic review of level-II or level-I studies with inconsistent results.

The complexity and value of mid-level patterns of denials.

Finding patterns in denied claims makes the task of correcting and resubmitting them far more efficient. But ICD-10 exacerbates the problem. As use of ICD-10 grows, it will: Increase the number of codes substantially, increasing the granularity of data being captured about each claim, and combinatorial complexity will explode. Alter both payer and provider behavior, blowing away carefully cultivated pockets of tribal knowledge. Significantly challenge any method that uses the hierarchy or heuristics of existing code sets, rendering many software stopgaps useless. Spread codes far more broadly for a given procedure, making patterns far more difficult to detect using traditional analytics.

Posterior Cruciate Ligament Injuries in Very Young Children - A Case Report and Modern Review.

Background: Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not be able to verbalize a complete history of injury, may be difficult to examine, and plane film radiographs often appear within normal limits. Surgical treatment carries a risk of physeal arrest, but non-operative treatment may lead to recurrent instability and pain. Methods: We present a case report of a fouryear- old child with a PCL avulsion off the femoral insertion who received an open reduction and internal fixation (ORIF) with combined arthroscopic synovial debridement. We performed a literature review which compared the mechanism, location, concomitant injuries, work up and management of PCL injuries in children under the age of ten compared to adolescents and adults. Results: Nineteen months following surgery, physical examination revealed full knee range of motion and return to baseline function. Imaging studies confirmed there was no evidence of physeal arrest. Conclusion: ORIF with arthroscopy can be an effective method to treat PCL avulsions in children under the age of 10 years. This is similar to other case reports which reported positive outcomes with ORIF in this population. Large studies are needed to best understand optimal treatment modalities for PCL injuries in very young children. Level of Evidence: IV.

Closed bone graft epiphysiodesis for avascular necrosis of the capital femoral epiphysis.

BACKGROUND: Avascular necrosis (AVN) of the capital femoral epiphysis (CFE) after an unstable slipped capital femoral epiphysis (SCFE), femoral neck fracture or traumatic hip dislocation can result in severe morbidity. Treatment options for immature patients with AVN are limited, including a closed bone graft epiphysiodesis (CBGE). However, it is unclear whether this procedure prevents AVN progression. QUESTIONS/PURPOSES: We investigated whether early MRI screening and CBGE prevented the development of advanced AVN changes in the CFE and the rates of complications with this approach. METHODS: We prospectively followed all 13 patients (seven boys, six girls) with unstable SCFEs (six patients), femoral neck fractures (five patients), and traumatic hip dislocations (two patients) and evidence of early AVN treated between 1984 and 2012. Mean age at initial injury was 12 years (range, 10-16 years). Nine of the 13 patients had followup of at least 2 years or until conversion to THA (mean, 4.5 years; range, 0.8-8.5 years), including two with unstable SCFEs, the five with femoral neck fractures, and the two with traumatic hip dislocations. All patients had technetium scans and/or MRI within 1 to 2 months of their initial injury (before CBGE) and all had evidence of early (Ficat 0) AVN. Patients were followed clinically and radiographically for AVN progression. RESULTS: Six of the nine hips did not develop typical clinical or radiographic evidence of AVN. These six patients have been followed 6.3 years (range, 4.3-9.1 years) from initial injury and 5.9 years (range, 3.8-8.5 years) from CBGE. The remaining three patients were diagnosed with AVN at periods ranging from 3 to 6 months after CBGE. CONCLUSIONS: Early recognition and treatment of AVN with a CBGE may alter the natural history of this complication. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

An anatomic study of the distal femoral epiphysis.

BACKGROUND: The anatomy of the undulating distal femoral physis may be relevant to growth disturbance after physeal fractures and screw fixation about the physis. The surface anatomy of this physis has not been well described. METHODS: We performed an anatomic study on 26 cadaveric distal femoral epiphyses in specimens 3 to 18 years of age. High-resolution 3-dimensional surface scans were obtained and analyzed to determine the heights, approximate surface areas, and locations of the major undulations. RESULTS: Gross examination revealed lateral and anteromedial peripheral notches at the metaphyseal-epiphyseal junction, which deepen with advancing skeletal maturity. Within the epiphysis, there are 3 major undulations: a central ridge, lateral ridge, and medial peak, with mean heights of 5.5 mm (range, 2.9 to 9.8 mm), 2.5 mm (1.0 to 5.7 mm), and 2.9 mm (0.9 to 4.7 mm), respectively. The normalized height and surface area of each undulation decreased with increasing age, most dramatically in the central ridge. With respect to a line connecting the medial and lateral aspects of the physis, we found that the central peak passes more superior with younger age, and tends to be more posteriorly located. The lowest point of the physis is located either anteromedial or posterolateral. CONCLUSIONS: The central ridge, lateral ridge, and medial peak are the 3 major undulations in the distal femoral physis. The central ridge has the greatest height and most dramatic decrease in relative size with increasing age, suggesting structural importance. This anatomic data can guide metaphyseal and epiphyseal screw fixation. CLINICAL RELEVANCE: This study provides quantitative data on the topographic anatomy of the distal femoral physis, which can guide screw placement about the physis. These data may help identify fractures patterns with a greater risk of growth disturbance and key radiographic landmarks for guiding fracture reduction.

Patient-Reported Outcome Measures Following Surgical Intervention for Pediatric Sports-Related Injuries to the Knee: a Systematic Review.

PURPOSE OF REVIEW: Increased sports participation and early specialization has contributed to an increase in surgically managed musculoskeletal injuries to the knee in youth athletes. Established patient-reported outcome (PRO) measures have been extensively reported in adult patients to assess outcomes following sports-related knee surgery. However, current PRO measures for pediatric patients undergoing surgery for sports-related injuries have not been well-described. RECENT FINDINGS: Strong emphasis has been placed on patient-reported outcomes in recent years, and surgeons have identified many different scoring systems that could be used for sports-related knee injuries in children and adolescents. Recent research has shown that substantial variability exists in the reporting of PRO measures assessing outcomes following surgical management of sports-related knee injuries in pediatric patients. With a paucity of studies using PRO measures in surgically managed pediatric knee injuries, only procedures involving the anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) showed preference for particular systems. Pediatric ACL procedures predominantly use the International Knee Documentation Committee (IKDC) scoring system, while MPFL procedures predominantly use the Kujala scoring system. Further studies are necessary to determine preferred and appropriate patient-reported outcome measures for specific sports-related knee procedures in pediatric patients.

Optimal Fluoroscopic Angulation to Determine Intercondylar Notch Violation during Pediatric Medial Patellofemoral Ligament Reconstruction.

Previous anatomic data has suggested that during pediatric medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel must be angled distally and anteriorly to avoid damage to the distal femoral physis and then intercondylar notch. The purpose of this study was to determine the optimal degree of fluoroscopic angulation necessary to radiographically determine the presence of intercondylar notch violation. Fourteen adult cadaveric human femora were disarticulated and under fluoroscopic guidance, Schöttle's point was identified. A 0.62-mm Kirschner wire was then drilled through the condyle to create minimal notch violation. The femur was then placed on a level radiolucent table and coronal plane radiographs angled from -15 to 60 degrees were obtained in 5-degree increments to determine the fluoroscopic angle at which intercondylar notch violation was most evident. Grading of optimal fluoroscopic angle between two authors found that violation of the notch was the best appreciated at a mean angle of 43 ± 15 degrees from neutral. Results from this study emphasize the importance of angling the beam to essentially obtain a notch view to assess for a breech.

Modified Grammont Soft-Tissue Distal Patellar Realignment and Medial Patellofemoral Ligament Reconstruction for Patellofemoral Instability in Pediatric Patients.

Patellar dislocation is a relatively common pediatric injury, which often results in recurrent patellofemoral instability. An increased tibial tubercle-trochlear groove distance predisposes to patellofemoral instability and can be corrected with a distal realignment procedure. Soft-tissue distal realignment procedures must be used in the pediatric population to avoid the risks of premature physeal closure associated with tibial tubercle osteotomies. Several soft-tissue distal realignment procedures have been described, with no consensus as to the optimal technique. When combined with medial patellofemoral ligament reconstruction, distal realignment procedures can restore patellofemoral stability through the entire flexion arc. This article describes a modification of the Grammont distal patellar realignment procedure in conjunction with medial patellofemoral ligament reconstruction for the management of pediatric patellofemoral instability.

Sensitivity and Specificity of MRI in Diagnosing Concomitant Meniscal Injuries With Pediatric and Adolescent Acute ACL Tears.

Background: Preoperative diagnosis of concomitant meniscal tears in pediatric and adolescent patients with acute anterior cruciate ligament (ACL) deficiency is challenging. Purpose: To investigate the diagnostic performance of magnetic resonance imaging (MRI) in detecting meniscal injuries for pediatric and adolescent patients with acute ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The authors retrospectively identified patients aged ≤18 years who underwent acute ACL reconstruction between 2006 and 2018 at 2 tertiary academic hospitals. The primary outcomes were arthroscopically confirmed medial, lateral, or any (defined as medial and/or lateral) meniscal tears. To control for chronically deficient knees, patients must have received their MRI study within 4 weeks of injury and must have undergone surgery no more than 8 weeks after their MRI study. Preoperative MRI reports were compared with the gold standard of arthroscopically confirmed tears to calculate sensitivity, specificity, positive predictive value, and negative predictive value. In a secondary analysis, patients were stratified by age into 2 groups (≤13 or ≥14 years), body mass index-for-age data from the Centers for Disease Control were used to classify patients as obese or nonobese, and differences between sensitivity and specificity proportions were analyzed using chi-square test for homogeneity. Results: Overall, 406 patients with a mean age of 15.4 years (range, 10-18 years) were identified. The sensitivity, specificity, positive predictive value, and negative predictive value were as follows: for lateral meniscal (LM) tears, 51.0%, 86.5%, 78.3%, and 65.0%; for medial meniscal tears, 83.2%, 80.6%, 62.3%, and 92.5%; and for any meniscal tear, 75.0%, 72.1%, 81.5%, and 63.8%, respectively. In the stratified analysis, MRI was less specific for the following diagnoses: any meniscal tear in patients aged ≤13 years (P = .048) and LM tears in obese patients (P = .020). Conclusion: The diagnostic ability of MRI to predict meniscal injuries present at acute ACL reconstruction was moderate. Performance was poorest at the lateral meniscus, where MRI failed to detect 97 tears that were found arthroscopically. Specificity was significantly lower in younger patients for any meniscal tear and in obese patients for LM tears.

Current Concepts in Pediatric Septic Arthritis.

Septic arthritis continues to present challenges regarding the clinical diagnosis, workup, and definitive management. Urgent management is essential, so treating surgeons must efficiently work through differential diagnoses, identify concomitant infections, and do a timely irrigation and débridement. The incidence of methicillin-resistant Staphylococcus aureus is increasing, typically resulting in a more rapid progression of symptoms with more severe clinical presentation. The diagnostic utility of MRI has resulted in improved detection of concomitant septic arthritis and osteomyelitis, although MRI must not substantially delay definitive management. Early diagnosis followed by urgent irrigation and débridement and antibiotic therapy are essential for satisfactory long-term outcomes. Antibiotics should not be administered until blood cultures and arthrocentesis fluid are obtained, except in rare cases of a septic or toxic patient. Once cultures are obtained, empiric antibiotic therapy should commence and provide coverage for the most likely pathogens, given the patient's age. Laboratory markers, especially C-reactive protein, should be followed until normalization and correlate with resolution of clinical symptoms. Definitive antibiotic selection should be shared with a pediatric infectious disease specialist, who can help guide the duration of treatment.

ACL Reconstruction Delay in Pediatric and Adolescent Patients Is Associated with a Progressive Increased Risk of Medial Meniscal Tears.

BACKGROUND: We sought to investigate the relationship between the time from an anterior cruciate ligament (ACL) tear to the surgical procedure and meniscal tears in the pediatric and adolescent population. METHODS: Patients who were ≤18 years of age and had undergone an ACL reconstruction from 2006 to 2018 were identified in a retrospective, multicenter cohort. The primary outcomes were arthroscopically confirmed medial meniscal or lateral meniscal tears specifically and, in general, if any meniscal tear was present (medial and/or lateral). A multivariable Poisson regression model was used to determine whether the time from the injury to the surgical procedure was a risk factor for subsequent meniscal injury, after controlling for sex, age, and body mass index (BMI). Multivariable Poisson regression was also used to characterize associations of age, sex, and BMI with meniscal injury. RESULTS: In this study, 546 patients with a mean age (and standard deviation) of 15.3 ± 1.6 years were identified. For each week that the surgical procedure was delayed, there was a 2% increased risk of a medial meniscal tear (adjusted relative risk [ARR], 1.02 [95% confidence interval (CI), 1.01 to 1.03]). The weekly increase in risk of a medial meniscal injury was significant for male patients (ARR, 1.03 [95% CI, 1.01 to 1.05]), but not for female patients (ARR, 1.00 [95% CI, 0.97 to 1.04]), even though the effect modification was not significant (p = 0.24). Obese male patients had a 77.9% increased risk of medial meniscal tear for each 10-week delay (p < 0.001). The use of crutches was associated with a decreased risk of medial meniscal tears (ARR, 0.47 [95% CI, 0.34 to 0.64]). CONCLUSIONS: In pediatric and adolescent patients, the risk of meniscal injury is substantial after an ACL tear. A delay from the injury to the surgical procedure was associated with a 3% weekly increased risk of medial meniscal injury for male patients, but not for female patients. The increased risk of medial meniscal injury with delays to the surgical procedure was particularly high for obese male patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purposeful Closed Reduction and Pinning in Unstable Slipped Capital Femoral Epiphysis Results in a Rate of Avascular Necrosis Comparable to the Literature Mean.

The standard treatment of stable slipped capital femoral epiphysis (SCFE) is generally accepted to be in situ pinning. Controversy exists regarding the treatment of unstable SCFE, including the role of a purposeful closed reduction or open reduction. The objective of this study was to investigate the rate of avascular necrosis (AVN) with purposeful closed reduction and in situ pinning of unstable SCFE. The authors retrospectively reviewed 221 patients with 302 SCFE hips treated with in situ pinning between 2000 and 2014. Forty-eight patients (50 hips) presented with an unstable SCFE. All unstable SCFEs were treated by a gentle reduction method with traction and hip internal rotation followed by pinning. Southwick angles were measured prior to reduction and at the first postoperative visit. No stable SCFEs developed AVN. Thirteen (26%) unstable SCFEs developed AVN. Avascular necrosis developed in 7 of 17 (41%) hips screened with magnetic resonance imaging vs 6 of 33 (18%) hips screened with plain radiographs alone. Mean change in Southwick angle was 28°±8° in the AVN group vs 18°±18° in the no AVN group (P=.18). Despite potentially inflating the rate with the use of early detection magnetic resonance imaging, the authors found an AVN rate comparable to that in the published literature with the use of gentle purposeful reduction on a fracture table, and no statistical differences in reduction amount between patients with and without AVN. Gentle purposeful reduction appears to be a reasonable low morbidity option in the treatment of unstable SCFE without a clear increase in risk of AVN. [Orthopedics. 2021;44(2):92-97.].

A prospective randomised study on efficacy of music for decreasing preoperative anxiety in children.

BACKGROUND: The operating room can be a frightening environment for paediatric patients. This study investigated whether music medicine can mitigate preoperative anxiety in children. MATERIALS AND METHODS: One hundred and fifty children undergoing general anaesthesia were randomised to listen to music of the child's choice, lullaby music or no music before induction. Heart rates were measured in the waiting room, upon first entry into the operating room and just prior to induction. RESULTS: There was no significant difference in average heart rate change from the waiting room to induction in the patient choice, lullaby and control groups. Older age was associated with higher heart rate changes between baseline and entering the operating room. Pharmacologic sedation showed a significant beneficial effect on heart rate change at induction. CONCLUSION: Use of music medicine in the operating room does not show efficacy to reduce anxiety in children based on heart rate changes.