Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Donor-Site Morbidity for Iliac Crest Harvesting for Pediatric Scaphoid Nonunion.

PURPOSE: Screw fixation with iliac crest bone grafting (ICBG) is a well-studied treatment for pediatric scaphoid nonunions. Studies in adults, as well as in pediatric spine fusions, have demonstrated high rates of complications with ICBG, including longer-term donor site pain. We hypothesized that in pediatric patients undergoing ICBG for scaphoid nonunion, the donor site complication rate would be lower than that reported in other populations. METHODS: Records of patients ages 0-18 years at a single institution undergoing surgical reconstruction for scaphoid nonunion from 1995 to 2016 were reviewed. Patient and surgical variables were recorded, including how ICBG was harvested. Donor site complications were recorded, including donor site pain beyond 30 days after surgery, infection, peri-incisional or lower extremity numbness at any point after surgery and reoperation at the donor site at any time point after surgery. RESULTS: During the study period, 119 wrists in 117 patients underwent internal fixation and ICBG for scaphoid nonunion. The average age was 16 years; mean follow-up was 1 year. The majority of wrists (73, 62.9%) underwent harvest of both outer and inner tables of the iliac crest; 38 (31.9%) had only outer table harvested; 5 (4.3%) had only cancellous graft harvested. Ten wrists (8.4%) had a donor site complication. The most common donor site complication was donor site pain beyond 30 days after surgery (5, 4.2%), followed by numbness (4, 3.4%). No infections, seromas, or reoperations at the donor site occurred. In comparison to those subjects who did not experience complications, we found no difference based on the age at surgery or the type of graft used. Female patients were more likely to have a recorded complication than males. CONCLUSIONS: Donor site morbidity for iliac crest grafting in pediatric patients undergoing scaphoid nonunion surgery appears to be lower than that previously reported in adult patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Corrective Osteotomy for Symptomatic Radial Head and Neck Malunions in the Skeletally Immature.

BACKGROUND: Radial head and neck fracture malunion can lead to pain, stiffness, deformity, and functional limitations. This study analyzed the early radiographic and functional outcomes of corrective osteotomy for symptomatic radial head and/or neck malunion in skeletally immature patients. METHODS: Thirteen pediatric patients treated with corrective osteotomy for symptomatic radial head and/or neck malunion from 2004 to 2018 were identified. Radiographic union, range of motion, pain, and complications were recorded. Functional outcomes were assessed using the Broberg and Morrey Elbow Scale. RESULTS: The average age at the time of surgery was 12.3 years (range: 8.6 to 16.3). The mean time from injury to osteotomy was 7.5 months (range: 2 to 24.1 mo). Before osteotomy, mean radial head-shaft angulation was 23 degrees (range: 5 to 57 degrees), mean displacement was 76% (range: 0 to 55), average elbow flexion contracture was 18 degrees (range: 0 to 60 degrees), and average elbow flexion was 112 degrees (range: 95 to 135 degrees). After a mean follow-up of 14.3 months, 12 of 13 osteotomies (92%) healed; 1 patient had a painless nonunion. The number of patients reporting pain decreased from 9 to 2 ( P =0.012). Radiographic alignment and range of motion improved in all patients. Mean angulation and displacement improved to 8 degrees (range: 2 to 15 degrees, P =0.001) and 3% (range: 0 to 18 degrees, P =0.001), respectively. Mean elbow flexion contracture was reduced to 5 degrees (range: 0 to 30 degrees, P =0.008), and the average elbow flexion increased to 128 degrees (range: 100 to 135 degrees, P <0.001). Three patients underwent implant removal for complications, including heterotopic ossification and avascular necrosis. Physeal arrest did not lead to any adverse sequelae. The sole case of avascular necrosis had a reduced range of motion but no pain. The mean postoperative Broberg and Morrey score was 91.1; 7 patients had excellent postoperative scores, 4 good, and 2 fair. CONCLUSIONS: Corrective osteotomy for symptomatic malunion of the radial head and/or neck in skeletally immature patients can improve elbow alignment, motion, pain, and function. Preservation of the soft-tissue attachments to the proximal epiphysis and rigid internal fixation are critical components of this surgical technique. LEVEL OF EVIDENCE: Therapeutic Level IV.

Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program.

OBJECTIVE: To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program. BACKGROUND: Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain. METHODS: Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills. RESULTS: For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent." CONCLUSIONS: Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.

Jumping on the Bandwagon: Comparing the Efficacy of Chlorhexidine Versus Povidone-Iodine Preoperative Skin Antiseptic in Preventing Surgical Site Infections Following Pediatric Orthopaedic Surgery.

BACKGROUND: Adult literature has demonstrated chlorhexidine (CH) superiority at preventing surgical-site infections when compared with povidone-iodine (P-I). The purpose of this study is to compare the rate of postoperative infections after preoperative skin cleansing with either CH or P-I in pediatric orthopaedic surgery in an effort to identify superiority. METHODS: We retrospectively identified all patients (18 y and below) that underwent orthopaedic surgery at our institution in 2015, when P-I was the preoperative skin antisepsis of choice, and in 2018, when a change in protocol resulted in more frequent use of CH. Open fractures, infections, neuromuscular, and tumor surgeries were excluded. Orthopaedic surgeries were classified according to their subspecialty (sports-related/upper extremity, hip and lower extremity, trauma-related, or spine procedure). A 1:1 propensity score matching was conducted within each procedure group on the basis of age, sex, and year using nearest-neighbor matching. Spine procedures could not be matched and were subsequently excluded from analyses. RESULTS: Propensity score matching matched 1416 CH cases with 1416 P-I controls. The infection rate for CH was 19 infections per 1000 cases (27/1416; 1.9%) compared with an infection rate of 11 infections per 1000 cases (16/1416; 1.1%) for P-I subjects. No difference was detected in infection rate across preoperative skin antisepsis groups (P=0.12). Moreover, it was found that CH and P-I resulted in significantly equivalent infection rates to within ±1.5% (P=0.004). When stratified by procedure type, CH used in sports/upper extremity procedures resulted in 29 more infections per 1000 cases compared with P-I use (16/450; 3/450; P=0.005). No difference was detected in infection rate across CH and P-I skin antisepsis groups in lower extremity procedures (9/792; 8/792; P=1.00) or in trauma-related procedures (3/174; 4/174; P=1.00). CONCLUSIONS: CH and P-I are both protective against postoperative infections after sports/upper extremity, lower extremity, and trauma-related pediatric orthopaedic procedures. P-I may provide improved protection over CH as a preoperative skin antisepsis in upper extremity and sports-related procedures. LEVEL OF EVIDENCE: Level III-comparative cohort.

Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons' practice.

BACKGROUND: Evidence for surgical coaching has yet to demonstrate an impact on surgeons' practice. We evaluated a surgical coaching program by analyzing quantitative and qualitative data on surgeons' intraoperative performance. METHODS: In the 2018-2019 Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 practicing surgeons in multiple specialties at four academic medical centers were recruited to complete three peer coaching sessions, each comprising preoperative goal-setting, intraoperative observation, and postoperative debriefing. Coach and coachee rated the coachee's performance using modified Objective Structured Assessment of Technical Skills (OSATS, range 1-5) and Non-Technical Skills for Surgeons (NOTSS, range 4-16). We used generalized estimating equations to evaluate trends in skill ratings over time, adjusting for case difficulty, clinical experience, and coaching role. Upon program completion, we analyzed semi-structured interviews with individual participants regarding the perceived impact of coaching on their practice. RESULTS: Eleven of 23 coachees (48%) completed three coaching sessions, three (13%) completed two sessions, and six (26%) completed one session. Adjusted mean OSATS ratings did not vary over three coaching sessions (4.39 vs 4.52 vs 4.44, respectively; P = 0.655). Adjusted mean total NOTSS ratings also did not vary over three coaching sessions (15.05 vs 15.50 vs 15.08, respectively; P = 0.529). Regarding patient care, participants self-reported improved teamwork skills, communication skills, and awareness in and outside the operating room. Participants acknowledged the potential for coaching to improve burnout due to reduced intraoperative stress and enhanced peer support but also the potential to worsen burnout by adding to chronic work overload. CONCLUSIONS: Surgeons reported high perceived impact of peer coaching on patient care and surgeon well-being, although changes in coachees' technical and non-technical skills were not detected over three coaching sessions. While quantitative skill measurement warrants further study, longitudinal peer surgical coaching should be considered a meaningful strategy for surgeons' professional development.

Sprengel's deformity: an analysis of surgically and nonsurgically treated patients.

BACKGROUND: Sprengel's deformity is a congenital anomaly of the scapula and can be associated with reduced shoulder mobility and esthetic concerns. Controversies remain regarding its natural history, radiographic findings, and optimal treatment strategy. METHODS: A total of 74 Sprengel's shoulders in 71 patients presenting to a pediatric referral hospital were retrospectively reviewed including 24 surgically treated shoulders. Median age at initial presentation was 3.8 years. Median age at the final follow-up was 9.6 years. RESULTS: Twenty shoulders were analyzed for range of motion across time. The median composite abduction range was initially 105° and at the last time-point 98°, with a median loss of 15° over 5 years (P = .007). A total of 26% of the nonsurgical shoulders reported pain at the latest follow-up, compared with 1 surgical patient (4%) (P = .028). Older age was independently associated with pain (P < .001); this effect was only seen in nonsurgical patients. Radiographically, the glenoid inclination angle (GIA) independently correlated with the abduction range (P = .001). Surgically treated shoulders underwent a modified Woodward procedure at a median 4.8 years of age. At a median follow-up of 41 months, the abduction range improved in the surgical group from 90° preoperatively to 110° postoperatively, with a median gain of 40° (P < .001). The median GIA changed from -2° to 4° with a median gain of 9° (P = .004). CONCLUSIONS: The natural history of untreated Sprengel's deformity may be one of gradual decline in the abduction range, with a proportion of patients developing pain in adolescence. The GIA correlates with the shoulder abduction range. Surgery with a modified Woodward procedure may alter the natural history of the condition by improving motion and reducing risk of pain later in life.

Later in Career Surgeon Performance Assessment: Why, When, What, and by Whom.

BACKGROUND: The average age of practicing surgeons is increasing, consistent with the overall population; one third of Americans are over 55 years of age. Aging is clearly associated with varying loss of skills, yet there are no age-based state or federal requirements for professional skill assessment; or age-specific criteria for board certification, recertification, or retirement. Capability based policies are preferred to age based criteria (3) but very few organizations have such policies in place. METHODS: A Delphi method study was utilized to answer: When should a surgeon's performance be assessed? If mandatory, then at what age? If adverse events triggered, then what events? What should be assessed? By whom? And, who determines the result-based actions? A systematic literature review indicated institutional stakeholders. On the basis of this a 20-member expert panel was created drawing from 13 US pediatric institutions: orthopaedic surgical department-division chiefs (14), children's hospital general counsel (3), surgical chief responsible for hospital bylaws-medical peer review (1), OR nursing managers (2). Three rounds of iterative questionnaires were utilized. RESULTS: A 100% response rate was achieved. Consensus supported recommendations included: Mandatory assessments should start at the age of 65 years, after a medical disability, and or at the request of other health care professionals. Assessments should include criteria for behavioral health, mental capacity, physical health, surgical performance, 360 human resource reviews, and surgical adverse events. Assessments should be performed by an external group with validated tools and reviewed by the department and overall surgeon-in-chief. The final decisions for an action plan based on results should be made by departmental and overall surgeon-in-chief. CONCLUSIONS: Our expert panel Delphi method study recognized aging is a risk factor in performance and recommended surgeon assessments should be automatically triggered by the age of 65 years, negative health events, or serious performance concerns. Assessments should be multifaceted, fair, reliable with minimal bias, and performed by an external professional group. Decisions should be managed by departmental and surgical chiefs. LEVEL OF EVIDENCE: Level V.

Single-Bone Forearm as a Salvage Procedure in Recalcitrant Pediatric Forearm Pathologies.

PURPOSE: To report on the outcome of single-bone forearm reconstruction (SBFR) as a salvage procedure in pediatric forearm pathologies. METHODS: Twenty-eight forearms in 27 patients (median age, 9.6 years; range, 3.4-29.7 years) treated with SBFR at a pediatric referral center were included in the study. Records and radiographs were retrospectively analyzed. Median follow-up was 84 months (range, 24-261 months). The most common underlying condition was multiple hereditary exostoses (MHEs) (17 of 28), followed by brachial plexus birth injury (5 of 28), Ollier disease (2 of 28), congenital radial head dislocation (2 of 28), and others (2 of 28). RESULTS: By 4 months (range, 2-10 months) after surgery, 21 of 28 forearms had united. Median resting postoperative forearm rotation was 10° pronation (range, neutral to 25° pronation). Before surgery, pain was present in 23 of 28 forearms. At the latest follow-up, pain was present in 5 of 28 forearms. In three of the 5 forearms with residual pain, this was attributed to ulnohumeral degenerative changes that existed prior to SBFR. Following SBFR, elbow flexion-extension range was maintained. In the subgroup with MHEs, radial articular angle was maintained (median, 37°-30°) and carpal slip percentage improved significantly (median, 40%-12%). Complications occurred in 8 forearms: 3 cases of nonunion in older patients (age, 30, 20, and 14 years), 2 cases of traumatic juxtaimplant fractures following successful union, 1 case of infection, 1 case of compartment syndrome, and 1 case of persistent radiocapitellar impingement. All complications were successfully treated. When stratified by age, none of the patients in the younger group (16 forearms, age < 12 years) had nonunions or pain at latest follow-up. CONCLUSIONS: The SBFR is an old, but generally reliable, option as a single-stage salvage procedure for a number of recalcitrant pediatric forearm pathologies. Success rate may be higher in younger patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents.

PURPOSE: To investigate the clinical results and patient-reported outcomes following surgical treatment for triangular fibrocartilage complex (TFCC) tears in the pediatric and adolescent population. METHODS: We reviewed 149 patients with 153 arthroscopy-confirmed TFCC tears. Mean age at surgery was 15.5 years (range, 7-19 years). There were 86 females. Plain radiographs and magnetic resonance imaging were used to characterize bony and soft tissue pathology. Mayo Modified Wrist Score (MMWS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Short Form assessed functional outcomes. Median patient follow-up was 21.8 months (IQR:5.9-55.4). RESULTS: Pre-operatively, all patients had wrist pain or instability with activities. The median pre-operative MMWS was 80 (interquartile range [IQR], 65-90). Fifty-six (35%) presented with positive ulnar variance. Concomitant pathology included distal radioulnar joint (DRUJ) instability (14%), ulnocarpal impaction (20%), ulnar styloid nonunion (33%), and distal radius growth arrest (30%). On arthroscopy, there were 15 (10%) isolated 1A, 79 (52%) 1B, 1 (1%) 1C, 30 (20%) 1D tears, and 25 (16%) cases of multiple tears. Twenty-six percent of wrists underwent TFCC debridement, 68% arthroscopy-assisted repair, 6% both for combined tears. Fifty-one percent of wrists underwent bony procedures-most commonly ulnar-shortening osteotomy to achieve neutral ulnar variance (40%) and symptomatic ulnar styloid nonunion excision with concomitant TFCC repair (39%). At final follow-up, pain, wrist range of motion, DRUJ stability, ulnar variance, and MMWS (median, 95 [IQR, 86.5-100]) improved significantly. The median PROMIS T-score at final follow-up was 57 (IQR, 45-57). The MMWS was better in those with concomitant bony procedures at index surgery than those with only repair or debridement of TFCC tears. CONCLUSIONS: Most pediatric TFCC tears are posttraumatic and peripheral. Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury.

PURPOSE: Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. METHODS: From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. RESULTS: We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. CONCLUSIONS: Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Congenital pseudarthrosis of the clavicle: surgical decision making and outcomes.

BACKGROUND: Congenital pseudarthrosis of the clavicle (CPC) is a rare entity in which the primary ossification center of the clavicle fails to coalesce. The natural history of CPC is unknown, and there is controversy regarding surgical vs. conservative treatment. METHODS: A retrospective review of 47 pediatric patients treated for CPC was performed. The Quick Disabilities of the Arm and Shoulder (QuickDASH) survey and the Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity domain were used to assess overall patient satisfaction, function, and quality of life after treatment. RESULTS: Twenty-four of 47 (51%) patients underwent surgical treatment. Of these, 9 patients (38%, 9/24) underwent surgery at <18 months of age using suture fixation alone, whereas the older 15 surgical patients (15/24, 62%) were treated with plate fixation. The younger surgical cohort had a nonunion rate of 43% (3/7) compared with 13% (2/15) in the older cohort. All surgical patients had resolution of preoperative symptoms. Eleven (11/24, 46%) surgical subjects responded to the follow-up survey. Upper extremity function normalized according to the QuickDASH survey (score of 0 for all subjects). The median PROMIS upper extremity domain score was 55, which was also in the normal range. CONCLUSIONS: This series of CPC patients improves our understanding of treatment options and outcomes of surgical treatment. All surgical patients had resolution of preoperative symptoms. Patients treated surgically with stable fixation at an older age had higher rates of union than those treated in infancy with suture fixation. Patient-reported outcomes were favorable overall.

Brachial Plexus Birth Injury in the Preterm Infant: Suspecting the Unsuspected.

BACKGROUND: Prematurity is usually considered as a protective factor for brachial plexus birth injury (BPBI). However, BPBI can occur in the preterm infant, and can cause significant dysfunction and morbidity. There is scant literature regarding this subgroup of patients with BPBI. METHODS: Patients were identified through a retrospective search of a prospective BPBI registry at a single tertiary pediatric referral center. Prematurity was defined as birth at or before gestational age of 36 (6/7) weeks. Thirty-six arms in 34 patients were included in this study. Data were obtained from patient charts documenting standardized brachial plexus clinical examinations at each visit, medical imaging, questionnaires for parents, and outside perinatal records brought in by parents. RESULTS: The youngest infant identified with BPBI was born at 23 weeks' gestation. Median birth weight was 3005 g (range: 580 to 4600 g). Twenty-nine arms in 28 patients were categorized into the "late preterm group" [34 to 36 (6/7) weeks gestation], and 7 arms in 6 patients were categorized into the "early preterm group" (<34 wk). Four of 6 (67%) subjects in the early preterm group were delivered vaginally in the breech position, compared with 4 of 28 subjects (14%) in the late preterm group (P=0.02). All 3 twin gestation infants with BPBI were the younger twin and born vaginally in the breech position. Delayed diagnosis (>7 d) occurred in 11 arms in 10 subjects (31%). Median delay in diagnosis was 73 days (range: 10 to 1340 d). Spontaneous recovery of antigravity elbow flexion occurred in 65% of arms (at median 5 mo, range: 1 to 17 mo). Overall, 89% (32/36) of arms with BPBI had residual neurological deficit and 53% (19/36) of arms underwent at least 1 surgical intervention at latest follow-up (median age at latest follow-up: 60 mo, range: 1 to 237 mo). CONCLUSIONS: BPBI in preterm infants is rare but does occur and can cause significant morbidity. Delayed diagnosis of BPBI is common in preterm infants. A high index of suspicion should be maintained to avoid delayed diagnosis that may jeopardize treatment options. Preterm infants may be more susceptible to birth trauma from breech deliveries and shoulder dystocia, as evidenced by far higher incidence of these factors compared with term infants with BPBI in literature. LEVEL OF EVIDENCE: Level IV-case series.

Surgical Reconstruction of Missed Monteggia Lesions in Children.

BACKGROUND: Chronic Monteggia lesions in children may cause pain, deformity, decreased range of motion, and neurological symptoms. Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in efforts to maximize long-term upper limb function. The purpose of this investigation was to assess the clinical and radiographic results of a modified surgical technique for missed Monteggia fracture-dislocations. METHODS: A retrospective evaluation of 52 patients who underwent surgical reconstruction of missed Monteggia fracture-dislocations at a tertiary pediatric hospital was performed. The median patient age at the time of surgery was 6.8 years, and the median time from injury to surgery was 12.9 weeks. Electronic medical records, including clinic notes, radiographic images, and operative reports, were reviewed for study analysis. Median clinical and radiographic follow-up was 19.1 months. RESULTS: The median elbow range of motion improved from 108 degrees of flexion and 5 degrees short of full extension preoperatively to 140 degrees of flexion (P<0.001) and full extension (P=0.10) postoperatively. Forearm range of motion also improved from a median of 80 degrees of pronation and 58 degrees of supination preoperatively to 80 degrees of pronation (P=0.54) and 80 degrees of supination (P<0.001) postoperatively. Congruent radiocapitellar alignment was maintained in 39 patients (75%). Nine patients (17%) had redislocation of the radiocapitellar joint, and 4 patients (8%) had radiographic resubluxation. Six of the 9 patients who experienced redislocation underwent early revision and achieved uncomplicated longer term results. Patients who received repair of the native annular ligament were more likely to achieve lasting radiocapitellar joint stability (P=0.03) when compared with patients who received annular ligament reconstruction or if the annular ligament was not addressed. CONCLUSION: Meaningful improvements in elbow motion and radiocapitellar stability can be safely achieved in the majority of children following surgical reconstruction of missed Monteggia lesions. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient.

INTRODUCTION: The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes. METHODS: A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest. RESULTS: Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest. CONCLUSIONS: Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children. LEVEL OF EVIDENCE: IV-case series.

The Anterior Approach for Transfer of Radial Nerve Triceps Fascicles to the Axillary Nerve.

Nerve transfers are an increasingly popular method for surgical treatment of nerve injuries. One of the most popular of these is the transfer of radial nerve triceps fascicles to the axillary nerve. The most common approach for this transfer is the posterior approach, which gives excellent access to both nerves but is not easy to combine with other nerve transfers. We describe here an alternative, the anterior approach, that offers safe access to both radial and axillary nerves and has the added advantage of compatibility with approaches for other common nerve transfers.

Pollicization of the Index Finger in the United States: Early Readmission and Complications.

PURPOSE: Pollicization is a well-accepted treatment for thumb hypoplasia, yet little is known about the reasons why patients return early in the postoperative period and complications that occur after surgery. The purpose of this investigation was to describe 30-day returns, readmission, and complication rates after pollicization in the United States. METHODS: A total of 459 pollicization procedures performed in 408 patients at 38 U.S. pediatric hospitals from 2003 to 2014 were identified using the Pediatric Health Information System database. A stepwise search strategy identified returns and readmissions within 30 days after pollicization to quantify complications and/or additional procedures. Risk factors for readmission and complications were compared across groups using uni- and multivariable general linear modeling. RESULTS: There were 61 patients who returned to the hospital (emergency department, ambulatory surgery, or inpatient hospitalization) within 30 days of their pollicization. Of those, 39 patients returned for suture removal, cast changes, or other expected aspects of postoperative care. The remaining 22 patients had a total of 26 complications, accounting for a 4.8% complication rate. The majority had vascular complications and wound problems. Single complications ranging from wound infection to hemorrhage were found in 20 cases. Overall, 35 of the 61 returns were readmitted to the hospital for treatment of complications or additional procedures. There was no effect of age group, diagnosis, geographical region, or physician subspecialty on the likelihood of complication or readmission. CONCLUSIONS: Sixty-one patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%), most commonly vascular in nature. These baseline data are informative because they identify opportunities for future preventative measures and quality improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Recovery of Motor Nerve Injuries Associated With Displaced, Extension-type Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Nerve injuries occur in approximately 11% of pediatric extension supracondylar humerus fractures (SCHF), yet there is scarce literature to guide clinicians on management. The primary goal of this study was to report the presentation, treatment, and outcome of motor nerve injuries associated with extension SCHF. Our secondary goal was to determine which injury and treatment factors were associated with prolonged motor nerve recovery. METHODS: Two hundred forty-four traumatic nerve injuries associated with extension SCHF treated at a single institution between 1996 and 2012 were reviewed. Patients with iatrogenic nerve injuries or subjective paresthesias without motor deficit were excluded. Univariable and multivariable general linear modeling were used to compare recovery times across nerve injury types and to determine the effect of injury and treatment characteristics on recovery time. RESULTS: Patients were a mean age of 6.7 years, with 89% presenting with a single nerve injury and 29% of the cohort experiencing a concurrent vascular injury. The majority of injuries (62%) were to the median nerve. Forty-three (18%) cases had acute nerve decompression at the time of fracture fixation. Five cases required subsequent surgery for poor nerve recovery; none of which underwent initial nerve decompression. Thirty-one patients were lost to follow-up after injury. Median time to nerve recovery was 2.3 months (IQR 1.4 to 3.7 mo); 60% of injuries had nerve recovery by 3 months and 196 (92%) patients had complete nerve recovery at final follow-up. A greater percentage of isolated median nerve (70%) injuries recovered within 3 months compared with radial nerve (42%) injuries (P=0.01). Multivariable analysis demonstrated that multiple nerve injuries took 54% longer to recover than single median nerve injuries (P=0.01), and single radial nerve injuries took 30% longer to recover than single median nerve injuries (P=0.04). CONCLUSIONS: The majority of nerve injuries associated with pediatric extension SCHF recover within 6 months without acute nerve decompression. The presence of either an isolated radial nerve injury or multiple nerve injuries is associated with prolonged motor recovery. LEVEL OF EVIDENCE: Level IV.

Decreasing Resource Utilization Using Standardized Clinical Assessment and Management Plans (SCAMPs).

BACKGROUND: Standardized clinical assessment and management plans (SCAMPs) are a novel quality improvement initiative shown to improve patient care, diminish practice variation, and reduce resource utilization. Unlike clinical practice guidelines, a SCAMP is a flexible algorithm that undergoes iterative updates based on periodic data collection and review. We recently implemented a SCAMP for the closed treatment of pediatric torus fractures. The purpose of this study is to analyze the effect of SCAMP implementation on resource utilization, practice variability, cost of care, and outcomes. METHODS: This study was a retrospective review of prospectively collected data on 273 patients with pediatric torus fractures. The pre-SCAMP cohort included 116 subjects from 2008 to 2010. The SCAMP cohort included 157 subjects from 2011 to 2013. The pre-SCAMP cohort was treated according to the judgment of attending fellowship-trained pediatric orthopaedic surgeons. The SCAMP cohort was treated with a standardized algorithm including radiographs and splint application at initial presentation, with a single follow-up at 3 weeks. Patient demographics were analyzed to verify comparability between cohorts. Follow-up data including clinic visits, x-rays and practice variability was recorded. Costing analysis was conducted using time-derived activity-based costing methodology. Outcomes were compared using Poisson regression analysis. Incident rate ratios (IRR) with 95% confidence limits were estimated. RESULTS: No differences in clinical results were observed between the pre-SCAMP and SCAMP cohorts, and all patients demonstrated return to baseline activity at final follow-up. Patient demographics were comparable across cohorts. The SCAMP cohort had a 48% reduction in clinic visits [IRR, 0.52; 95% confidence interval (CI), 0.44-0.60; P<0.001], 60% reduction in x-rays (IRR, 0.40; CI, 0.33-0.47; P<0.001), and a 23% reduction in x-rays per clinic visit (IRR, 0.77; 95% CI, 0.65-0.91; P<0.001). Furthermore, SCAMP implementation resulted in a 49% reduction in the overall cost of care. CONCLUSIONS: SCAMPs provide a novel alternative to CPGs to implement cost effective changes in Orthopaedic practice. For pediatric torus fractures, SCAMP implementation resulted in decreased practice variability, resource utilization, and overall cost of care while maintaining clinical outcomes. LEVEL OF EVIDENCE: Level 3.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children.

PURPOSE: We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes. METHODS: Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years). RESULTS: All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively. CONCLUSIONS: Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.