Assessment and Validation of Anterior Humeral Line for Diagnosing Supracondylar Humerus Fractures in the Pediatric Population.

INTRODUCTION: Pediatric supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in radiographic projection are common due to child discomfort and could lead to changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish whether rotational variations in elbow rotation leads to significant changes in AHL position and whether drawing the AHL based on the distal humerus versus shaft is more tolerant to rotation. METHODS: Fifty children with nonoperative supracondylar humerus fractures were identified with sub optimally positioned injury and well positioned follow-up lateral radiographs. The proportion of the bone anterior to the intersection of the AHL and the capitellum was measured using the humeral shaft versus distal humerus to guide position of the AHL. This process was repeated on ten pediatric humerus dry cadaveric specimens which were imaged in 5-degree rotational increments along the axis of the humeral shaft from -20 to +20 degrees. RESULTS: AHL position correlated poorly when measured on rotated lateral radiographs of clinical patients versus non-rotated lateral radiographs when using the distal humerus as a guide (intraclass correlation coefficient 0.14), compared with when using the humeral shaft as a guide (intraclass correlation coefficient 0.81). When assessing the pediatric humerus dry cadavers between the 2 techniques, there was greater statistically significant variation in rotated positions compared with the neutral position in the distal humerus AHL measurement approach compared with the humeral shaft AHL measurement approach, with the mean AHL within the central third of the capitellum for more rotational positions when using the shaft compared with the distal humerus. CONCLUSIONS: With rotated lateral elbow radiographs in supracondylar humerus fractures, utilizing the humeral shaft provides more consistent AHL measurements than utilizing the distal humerus, and thus drawing the line starting at the shaft of the humerus is recommended for surgical decision making.

An Anatomic and Radiographic Study of the Distal Tibial Epiphysis.

BACKGROUND: Although the undulating shape of the distal tibial epiphysis is well recognized, its anatomic features have not been well quantified in the literature. To guide the placement of surgical implants about the distal tibial physis, we investigated the topographical anatomy of the distal tibial epiphysis and explored the ability of standard radiographs to visualize the physis. METHODS: We studied 30 cadaveric distal tibial epiphyses in specimens 3 to 14 years of age. Anteroposterior (AP) and lateral radiographs were obtained of each specimen and then repeated after flexible radiopaque markers were placed on the major undulations. All radiographs were analyzed to determine the height or depth of each landmark, and measurements with and without markers for each landmark were compared using intraclass correlation coefficients (ICC). In 9 specimens, similar measurements were obtained on high-resolution 3-dimensional (3D) surface scans. RESULTS: There were 4 distinct physeal undulations usually present: an anteromedial peak (Kump's bump), a posterolateral peak, an anterior central valley, and a posterior central valley. On the 3D scans, Kump's bump averaged 5.0 mm (range, 3.0 to 6.4 mm), the posterolateral peak 2.4 mm (range, 1.2 to 5.0 mm), the anterior valley 1.3 mm (range, 0 to 3.6 mm), and the posterior valley 0.77 mm (range, 0 to 2.7 mm). Lateral radiographs with markers correlated with measurements from 3D scans better than those without markers (ICC=0.61 vs. 0.24). For AP radiographs, correlation was good to excellent regardless of marker use (ICC=0.76 vs. 0.66). CONCLUSIONS: There are 4 major undulations of the distal tibial physis. Kump's bump is the largest. A centrally placed epiphyseal screw in the medial/lateral direction or screws from anterolateral to posteromedial and anteromedial to posterolateral would tend to avoid both valleys. Particular caution should be taken when placing metaphyseal screws in the anteromedial or posterolateral distal tibia. Physeal undulations were more difficult to visualize on the lateral view. CLINICAL RELEVANCE: This study provides quantitative data on the topography of the distal tibial physis to aid hardware placement. Lateral views should be interpreted with caution, as the physeal undulations are not as visible, whereas AP views can be interpreted with more confidence.

Microdose protocol stereoradiography has similar reliability to standard low-dose protocol during concurrent Sanders skeletal maturity staging.

PURPOSE: Decreasing radiation exposure is important for scoliosis patients who require serial imaging. Microdose protocol stereoradiography is now increasingly utilized. Previous studies have reported similar reliability of concurrent Sanders skeletal maturity staging based on standard low-dose stereoradiography and standard hand radiographs. The purpose of our study was to investigate the reliability and radiation exposure of concurrent Sanders staging using microdose protocol compared to a standard protocol for adolescent idiopathic scoliosis. We hypothesized that surgeon-performed Sanders staging would have similar reliability when comparing microdose and standard-dose imaging protocols. METHODS: A randomized survey of 30 hand images using standard protocol spinal stereoradiography and an equal number from microdose protocol were distributed to six experienced pediatric orthopaedic spine surgeons. Images were graded by each surgeon according to the Sanders skeletal maturity grading system. Items were again randomized and graded after a 2-week interval. Fleiss' weighted kappa for inter and intraobserver reliability was calculated and an unpaired t test was used to test for significance. RESULTS: Interobserver reliability for all modalities was in the strong to almost perfect agreement (average weighted κ > 0.8) range. For the microdose protocol, κ was 0.82 and 0.84 for each separate round of grading. Standard low-dose protocol κ was 0.83 and 0.79. Intraobserver κ was 0.86 for microdose and 0.82 for standard. Average radiation for microdose was significantly less radiation (82.6%) than standard stereoradiography (0.3 ± 0.1 mGy vs. 1.9 ± 0.4 mGy, p < 0.001). CONCLUSIONS: Sanders staging reliability of a well-positioned hand during scoliosis stereoradiography was similarly excellent for both microdose and standard low-dose protocol. Microdose protocol used less radiation while still preserving the reliability of Sanders staging.

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.

The Cost of Maternity Leave for the Orthopaedic Surgeon.

INTRODUCTION: Maternity leave among orthopaedic surgeons is not well understood. This study seeks to quantify past and current maternal leave characteristics of female orthopaedic surgeons. METHODS: A survey was distributed to the members of the Ruth Jackson Orthopaedic Society and Women in Orthopaedics, an online group exclusive to female orthopaedic surgeons in practice or in training. The survey was open from April 2018 to October 2018 with access gained by way of a web-based link. Respondents were queried regarding demographics and maternity leave characteristics including age at conception, length of leave given/taken, and cost. RESULTS: A total of 801 surveys were completed with 452 surveys returning with information regarding past pregnancies. Of the 452 surgeons with children, the average leave offered was 4.6 ± 4.2 weeks for the first child, with 8.2 ± 7.4 weeks taken. A difference was observed (P < 0.001) between the amount of leave taken between residents (6.3 ± 5.0 weeks), fellows (8.3 ± 7.2 weeks), and practicing surgeons (9.6 ± 8.5 weeks). The average cost of the first leave was $40,932 ± 61,258. The average cost during training was different than during practice ($154 versus $45,350, P < 0.001). The length of leave offered (P = 0.05) and taken (P < 0.001) affects the cost, whereas delivery type, timing of stopping clinic, taking calls, and operating did not. Each additional week of leave offered saved a surgeon $2,583, and each additional week taken cost $3,252. DISCUSSION: Residents take shorter leaves than fellows and attendings. The cost of taking leave is substantial, and the cost during practice is higher than during training. The amount of leave taken is greater than the amount of paid leave offered.

Safe Drilling Paths in the Distal Femoral Epiphysis for Pediatric Medial Patellofemoral Ligament Reconstruction.

BACKGROUND: Anatomic surgical reconstruction of the medial patellofemoral ligament (MPFL) has been popularized for the treatment of recurrent patellar instability in the skeletally immature population. Previous anatomic studies have found that the femoral attachment point of the MPFL is very close to the distal femoral physis. PURPOSE: To establish the safe angles for drilling the distal femoral epiphysis for MPFL graft placement. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 23 cadaveric distal femoral epiphyses were scanned into high-resolution 3-dimensional images. Using computer-aided design, we identified and marked the femoral insertion site of the MPFL. Cylinders 8 mm in diameter were placed at varying angles to simulate the drill paths for placement of 6-mm interference screws with a 1-mm buffer. The distance from the MPFL footprint to where the tunnel first violated the physis, the intercondylar notch, or the distal cartilage was measured. We recorded the percentage of tunnels that caused violations before reaching 20 mm, the shortest length of a typical femoral tunnel socket. RESULTS: Measurements indicated that 41% of tunnels angled distally less than 10° violated the physis, 40% of tunnels angled distally more than 10° but anteriorly less than 10° violated the notch, and 27% of tunnels angled distally and anteriorly more than 20° violated the distal femoral cartilage. At least 90% of the tunnels were safe at 20 mm when the drill was angled between 15° and 20° both anteriorly and distally. CONCLUSION: Because of the anatomy of the distal femoral physis, drilling into the epiphysis from the MPFL attachment site at improper trajectories risks damage to sensitive structures. Angling the drill to an acceptable degree distally and anteriorly leads to less risk to the physis and notch, respectively, but angling too much leads to risk to the distal femoral cartilage. Small variations in the sagittal plane were better tolerated than variations in the coronal plane, so we recommend that more attention be paid to the radiographic anteroposterior view intraoperatively. It is safest to angle the drill distally and anteriorly approximately 15° to 20° in each plane from the MPFL attachment site. CLINICAL RELEVANCE: During drilling into the distal femoral epiphysis at the MPFL origin in skeletally immature patients, angling the drill appropriately 15° to 20° both distally and anteriorly minimizes damage to the physis, notch, and distal femoral cartilage.

A radiographic study of the distal femoral epiphysis.

PURPOSE: Previous studies have described the complex undulation pattern in the distal femoral physis. We investigated whether standard radiographs can visualize these landmarks, in order to guide hardware placement in the distal immature femur. METHODS: We studied 36 cadaveric immature femora in specimens 3 to 18 years of age. Anteroposterior (AP) and lateral radiographs were obtained with and without flexible radiodense markers placed on the major undulations and were analyzed to determine the relative height or depth of each topographical landmark. Intraclass correlation coefficients (ICCs) were calculated between measurements taken with and without markers for each undulation on each view. RESULTS: Examination of the specimens confirmed a central peak and anteromedial and posterolateral valleys as the major physeal structures. AP radiographs without markers correlated well with marked AP radiographs for all three landmarks (ICC = 0.92, 0.92, 0.91), but the lateral radiographs had lower correlations for the posterolateral valley (ICC = 0.36). The correlation between AP and lateral radiographs without markers on the posterolateral valley was also decreased compared to the other two landmarks (ICC = 0.28 versus 0.57 for the central ridge and 0.62 for the anteromedial valley). CONCLUSIONS: This is the first study to rigorously evaluate radiographic visibility of the distal femur physeal undulations. The position of the central ridge, anteromedial valley, and posterolateral valley are reliably seen on AP radiographs, while the lateral view is less consistent, especially for the posterolateral valley. We recommend that caution should be taken when placing screws near the posterolateral aspect of the epiphysis, as lateral views do not visualize those undulations well.