Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study.

BACKGROUND: Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study. METHODS: This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts. RESULTS: Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P<0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P<0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P=0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement. CONCLUSION: We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement. LEVEL OF EVIDENCE: II.

Risk Factors for Stiffness After Surgical Treatment of Pediatric Humeral Lateral Condyle Fractures: Results of a Multicenter Study.

INTRODUCTION: Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions. METHODS: A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed. RESULTS: Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions. CONCLUSIONS: This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients. LEVEL OF EVIDENCE: Level III: Therapeutic studies-Investigating the results of treatment.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE: Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively. METHODS: We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups. RESULTS: Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts. CONCLUSIONS: For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients. LEVEL OF EVIDENCE: Level II-therapeutic studies: prospective cohort study.

Association of race and socioeconomic status with time to pain control among pediatric trauma patients managed nonoperatively.

BACKGROUND: Few studies have evaluated racial/ethnic inequities in acute pain control among hospitalized injured children. We hypothesized that there would be inequities in time to pain control based on race/ethnicity and socioeconomic status. METHODS: We performed a retrospective cohort study of all injured children (7-18 years) admitted to our level 1 trauma center between 2010 and 2019 with initial recorded numerical rating scale (NRS) scores of >3 who were managed nonoperatively. A Cox regression survival analysis was used to evaluate the time to pain control, defined as achieving an NRS score of ≤3. RESULTS: Our cohort included 1,787 admissions. The median age was 14 years (interquartile range, 10-18), 59.5% were male, 76.6% identified as White, 19.9% as Black, and 2.4% as Hispanic. The median initial NRS score was 7 (interquartile range, 5-9), and the median time to pain control was 4.9 hours (95% confidence interval, 4.6-5.3). Insurance status, as a marker of socioeconomic status, was not associated with time to pain control ( p = 0.29). However, the interaction of race/ethnicity and deprivation index was significant ( p = 0.002). Specifically, the socioeconomic deprivation of a child's home neighborhood was an important predictor for non-White children ( p <0.003) but not for White children ( p = 0.41) and non-White children from higher deprivation neighborhoods experienced greater times to pain control (hazard ratio, 1.55; 95% confidence interval, 1.16-2.07). Being female, older, presenting with higher initial NRS scores, and having history of attention-deficit/hyperactivity disorder were all associated with longer times to pain control. Other injury characteristics and psychiatric history were evaluated but ultimately excluded, as they were not significant. CONCLUSION: Greater neighborhood socioeconomic deprivation was associated with prolonged time to pain control for non-White children admitted after injury and managed nonoperatively. Further work is needed to understand inequities in pain control for injured patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

K-wire Versus Screw Fixation in Displaced Lateral Condyle Fractures of the Humerus in Children: A Multicenter Study of 762 Fractures.

INTRODUCTION: Lateral humeral condyle fractures account for 12% to 20% of all distal humerus fractures in the pediatric population. When surgery is indicated, fixation may be achieved with either Kirschner-wires or screws. The literature comparing the outcomes of these 2 different fixation methods is currently limited. The purpose of this study is to compare both the complication and union rates of these 2 forms of operative treatment in a multicenter cohort of children with lateral humeral condyle fractures. METHODS: This retrospective study was performed across 6 different institutions. Data were retrospectively collected preoperatively and 6 weeks, 3, 6, and 12 months postoperatively. Patients were divided into 2 cohorts based on the type of initial treatment: K-wire fixation and screw fixation. Statistical comparisons between these 2 cohorts were performed with an alpha of 0.05. RESULTS: There were 762 patients included in this study, 72.6% (n=553) of which were treated with K-wire fixation. The mean duration of immobilization was 5 weeks in both cohorts, and most patients in this study demonstrated radiographic healing by 11 weeks postoperatively, regardless of treatment method. Similar reoperation rates were seen among those treated with K-wires and screws (5.6% vs. 4.3%, P =0.473). Elbow stiffness requiring further intervention with physical therapy was significantly more common in those treated with K-wires compared with children treated with screws (21.2% vs. 13.9%, P =0.023) as was superficial skin infection (3.8% vs. 0%, P =0.002), but there was no significant difference in nonunion rates between the two groups (2.4% vs. 1.3%, P =1.000). CONCLUSION: We found similar success rates between K-wire and screw fixation in this patient population. Contrary to previous studies, we did not find evidence that treatment with screw fixation decreases the likelihood of experiencing nonunion. However, given the unique complications associated with K-wire fixation, such as elbow stiffness and superficial skin infection, the treatment with screw fixation remains a reasonable alternative to K-wire fixation in these patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Spica Casting of Pediatric Femur Fractures: The Pain Management Experience at One Institution.

Objectives Currently, very little literature exists regarding the "fifth vital sign" in pediatric orthopedics, pain. Multiple studies have highlighted the utility of non-narcotic pain medications in treating acute pain. The objective of this study is to determine the type and amount of pain medication(s) administered and subsequently prescribed to pediatric patients ages six months to five years old with femur fractures treated with spica casting in the ER (emergency room) and OR (operative room). We also determined the incidence of spica cast change necessary for the two groups as a secondary outcome. Methods A retrospective review was completed at a single level 1 pediatric trauma center, evaluating 82 patients who met the inclusion criteria between six months to five years of age with isolated femoral shaft fractures requiring intervention at one institution. Descriptive statistics and Wilcoxon Rank-Sum or Fisher'sFisher's Exact test were used to assess differences between OR and ER groups for either continuous or categorical variables, respectively. The electronic medical record was then queried for demographic information, location of spica cast placement, hours in the hospital, and amount and type of analgesic medications administered and prescribed. Results Overall, we noted a preponderance of femur fractures in young males (72%), with the mean age of our cohort being 2.3 years old. Our patients spent a median of 20.9 hours in the hospital and had a median worst pain score of 7/10 during their hospital stay. No difference was found between standardized amounts of morphine equivalent administration between groups in the hospital. Upon discharge from the hospital, most patients received opioid and acetaminophen prescriptions (72% and 83%), but few received an ibuprofen prescription (24.4%). More spica casts placed in the ER needed to be revised in the OR compared to spica casts placed in the OR (57% vs. 8%, p<0.01). Conclusions There are various medication regimens for patients with femoral shaft fractures treated with spica casting at one institution. Our study revealed that patients received more prescription opioids if treated in the OR. Additionally, spica casting in the ER did not significantly decrease hospital stay, and it significantly increased the risk of needing a reduction in the OR in our institution.

Dynamic Supination in Congenital Clubfoot: A Modified Delphi Panel Approach to Standardizing Definitions and Indications for Treatment.

BACKGROUND: Dynamic supination is a well-recognized cause of congenital clubfoot deformity relapse. However, there is no consensus on how to diagnose it and there are varied approaches in its management. This study aims to define dynamic supination and indications for treatment by presenting consensus from an international panel of experts using a modified Delphi panel approach. METHODS: An international panel of 15 pediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements using a 4-point Likert scale on dynamic supination, clinical indications for treatment, operative techniques, and postoperative casting and bracing. All panelists participated in 2 voting rounds with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70% to 79%), and indeterminate (69% or less). RESULTS: Consensus was achieved for 34 of 51 statements. Panelists agreed dynamic supination is present when the forefoot is supinated during swing phase of gait with initial contact on the lateral border of the foot. There was also agreement that dynamic supination results from muscle imbalance between the tibialis anterior and the peroneus longus and brevis. There was no consensus on observation of hindfoot varus in dynamic supination, operative indications for posterior release of the ankle joint, or incisional approach for tibialis anterior tendon transfer. Reference to the calcaneopedal unit concept, planes of movement, and phases of gait were deemed important factors for consideration when evaluating dynamic supination. CONCLUSIONS: Consensus statements from the Delphi panel can guide diagnosis and treatment of dynamic supination in clubfoot deformity relapse, including clinical decision making regarding preoperative casting, surgical approach, and postoperative immobilization. Near-consensus and indeterminate statements may be used to direct future areas of investigation. LEVEL OF EVIDENCE: Level V.

Unicolumnar Pin Fixation of Type III Supracondylar Humeral Fractures Is Associated With Over 3 Times Higher Odds of Lost Reduction.

OBJECTIVES: To compare the rate of lost reduction between 2 groups of non-age-segregated type III supracondylar humeral fracture patients: a unicolumnar versus bicolumnar fixation group. DESIGN: Retrospective cohort study. SETTING: Pediatric Academic Trauma Center. PATIENTS: We identified 257 patients with type III supracondylar humerus fractures from surgical billing records over a 5-year period. There were 183 patients identified with bicolumnar fixation (71.2%) and 74 patients identified with unicolumnar fixation (28.8%). INTERVENTION: Closed reduction percutaneous pinning of the distal humerus. MAIN OUTCOME MEASURES: The primary outcome measure was difference in rate of lost reduction between patients with bicolumnar (lateral and medial column) and unicolumnar (lateral column only) fixation (Fig. 1). The reduction and fixation at the time of fluoroscopy was assessed using the Baumann angle, Gordon index, and anterior humeral line. Loss of reduction was assessed at time of healing, defined by a Baumann angle change ≥10 degrees and Gordon index of ≥50% (Fig. 2). RESULTS: There were 183 patients with bicolumnar fixation and 74 patients with unicolumnar fixation included in the study (average age 5.8 years; range, 2-14 years). The rate of lost reduction in patients with bicolumnar fixation was 6.01% (11/183), whereas 17.57% (13/74) of patients with unicolumnar fixation experienced lost reduction. These rates were significantly different (P = 0.008) with a 3.3 times higher odds (95% confidence interval = 1.3-8.6) of lost reduction with unicolumnar fixation. CONCLUSIONS: There is a statistically significant increase in the rate of supracondylar fracture loss of reduction for patients with unicolumnar fixation when compared with bicolumnar fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric and Adolescent Fractures of the Acetabulum Treated With ORIF: What Are Their Functional Outcomes?

OBJECTIVES: To evaluate the functional outcomes of pediatric and adolescent patients (<18 year old) who sustained acetabulum fractures that were treated with open reduction internal fixation (ORIF). DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Thirty-four pediatric and adolescent patients underwent acetabulum fracture ORIF between 2001 and 2018. Of the operatively treated patients, 21 patients had sufficient follow-up (>6 months), one died after fixation secondary to other traumatic injuries, and 12 patients were lost to follow-up. INTERVENTION: Acetabulum fracture ORIF. MAIN OUTCOME MEASUREMENT: The SF-36 Health Survey and Short Musculoskeletal Functional Assessment (SMFA) were compared with population norms. The modified Merle d'Aubigné clinical hip score, Matta radiologic outcome, and postoperative complications were also documented. RESULTS: Functional outcome data were available at a mean of 5 years 2 months. Mean SF-36 scores were 44.8 and 50.1 for the physical component score and mental component scores, respectively, which did not differ significantly from US population norms (physical component score mean: 50, P = 0.061 and mental component score mean: 50, P = 0.973). Furthermore, the mean SMFA Bother Index score was 18.6, which is not significantly different from the population norm mean of 13.8 (P = 0.268). However, the function index mean was 31.9, which was significantly worse than the population norm mean of 12.7 (P = 0.001). Two patients with a delayed reduction (>6 hours) of an acetabulum fracture dislocation had poor outcomes related to the development of avascular necrosis and post-traumatic osteoarthritis. CONCLUSION: In this small cohort, 86% (18/21) of these patients had a favorable functional outcome with the exception of the SMFA Functional Index that was significantly less than population norms. Although long-term follow-up is needed, we advocate for operative management of pediatric and adolescent acetabulum fractures when adult displacement and instability criteria are present. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction and Internal Screw Fixation of Transitional Ankle Fractures in Adolescents.

A triplane fracture is an example of a transitional fracture of adolescence that occurs because the distal tibial physis closes in a predictably asymmetric way from central to medial and then lateral. The triplane fracture is so named because the fracture lines propagate in 3 planes (axial, sagittal, and coronal) and thus appear on radiographs as a Salter-Harris III pattern on anteroposterior images and Salter-Harris II or IV on lateral images. The fracture occurs via a twisting mechanism (usually supination and external rotation) through the relatively weak open portion of the physis (axial) and propagates out the metaphysis (coronal) and/or epiphysis (sagittal) at the transition to the relatively stronger closed portion of the physis. Because the distal tibial physis closes over approximately an 18-month period in female patients from 12 to 14 years old and male patients from 13 to 15 years old, this is the age range in which triplane fractures occur. Triplane fractures account for approximately 5% to 10% of pediatric ankle fractures. The purpose of the present video article is to review the indications for operative treatment of transitional ankle fractures in adolescents and to detail the surgical technique specifically for open reduction and screw fixation of triplane fractures. The procedure is performed in order to provide anatomic reduction of the fracture and rigid fixation. Description: Surgical treatment of a triplane fracture is indicated if there is >2 mm articular displacement of the distal aspect of the tibia or if the fracture pattern is deemed unstable following closed reduction and casting. Preoperative planning (Step 1) involves the use of radiographs and computed tomography scans to determine accurate fracture classification, the intended reduction maneuver, possible blocks to reduction, and screw trajectory and length. Room setup and patient positioning (Step 2) include placing the patient in the supine position with a bump under the hip, as well as the placement of a ramp or stack of blankets under the affected limb and adequate general anesthesia with muscle relaxation to facilitate reduction. Incision and surgical exposure (Step 3) is performed with use of an anterior ankle incision at the anatomic plane between the extensor hallucis longus and extensor digitorum longus, protecting the neurovascular bundle (i.e., the anterior tibial artery and deep peroneal nerve). Open reduction and assessment of reduction (Step 4) begins by removing any soft tissue, such as the periosteum, that may be interposed in the fracture site precluding a reduction. The ankle is then put through internal rotation and dorsiflexion in order to reduce the fracture, utilizing direct visualization through the incision and fluoroscopy to verify reduction with <2 mm articular step-off. Screw placement (Step 5) typically involves a 2-screw construct, with 1 screw starting at the anterolateral distal tibial epiphysis aiming medially (and staying within the epiphysis) and a metaphyseal screw aiming from the anterior metaphysis to the posterior Thurston-Holland fragment. Closure and immobilization (Step 6) usually involve a layered skin closure, as no deep closure is necessary in most cases. A below-the-knee cast is applied with the ankle in neutral dorsiflexion. Alternatives: Nonoperative treatment typically involves closed reduction and long-leg cast immobilization. Rationale: Surgical treatment with reduction and screw fixation of triplane fractures is indicated for patients with >2 mm articular displacement or >3 mm physeal displacement of the distal aspect of the tibia. Achieving and maintaining reduction with screw fixation within these tolerances helps decrease the chance of arthritis development by 5 to 13 years postoperatively5,7. Expected Outcomes: Following treatment of a triplane fracture with reduction and screw fixation, full ankle range of motion and normal growth are anticipated. Postoperative follow-up continues until skeletal maturity or until 1 year postoperatively with evidence of continued growth by Park-Harris lines on sequential radiographs. Short-term recovery is expected to be excellent, and long-term results are expected to be good as long as <2 mm articular reduction is achieved and maintained5,7. Important Tips: General anesthesia with muscle relaxation helps with closed or open reduction.Computed tomography is valuable for determining the maximum articular displacement and for 3D surgical planning for screw trajectories.Be aware of the periosteum and perichondrial ring as possible soft-tissue blocks to reduction, and do not hesitate to visualize the periosteum with an open technique to achieve anatomic reduction. Acronyms and Abbreviations: AITFL = anterior inferior tibiofibular ligamentAP = anteroposteriorCT = computed tomography.

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

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

Closing the Gender Gap: Barriers to Success for Recruitment and Retention of the Female Orthopaedic Surgery Applicant.

¼ Orthopaedic surgery reports one of the lowest proportions of female residents among all medical specialties. While the number of female medical students has increased, our field has been particularly slow to respond to the gender gap. ¼ There are several barriers to increased female representation in orthopaedics, including "jock" culture and male dominance, the residency application process, pregnancy and lifestyle concerns, a limited number of mentors and role models, and lack of early exposure to the field. ¼ Organizations such as the American Academy of Orthopaedic Surgeons (AAOS), the Ruth Jackson Orthopaedic Society, The Perry Initiative, Nth Dimensions, and the J. Robert Gladden Society, as well as social media channels, are working to close the gender gap, but there is still more that needs to be done. ¼ By acknowledging and addressing these barriers, both at an individual and institutional level, we can hopefully bring more women into the field. This will ultimately benefit not only ourselves, but our patients as well.

Pediatric Proximal Radial Shaft Fractures Treated Nonoperatively Fail to Maintain Acceptable Reduction up to 70% of the Time.

OBJECTIVE: To compare early radiographic malalignment rates of conservatively treated proximal radial shaft fractures to more distal fractures. DESIGN: Retrospective cohort study. SETTING: A pediatric, Level 1 trauma center. PATIENTS/PARTICIPANTS: We identified a group of 401 pediatric patients who were treated for a complete radial shaft fracture at our institution. Of this group, 309 patients met our inclusion criteria for attempted nonoperative management and were evaluated in our study. INTERVENTION: Closed reduction and casting. MAIN OUTCOME MEASUREMENT: The primary outcome of the study was the failure rate of nonoperative management as defined by residual angulation of the radius assessed on follow-up radiographs. RESULTS: Proximal third fractures were significantly more likely to fail conservative treatment (P < 0.0001) as they exceeded angulation criteria 70% (32/46) of the time compared with more distal fractures (33%; 87/263). In terms of halves (P = 0.0003), the proximal half fractures failed 50% (55/111) of the time while 29% (57/198) of distal half fractures failed conservative treatment. Failure of closed reduction and casting was 4.6 times higher (95% confidence interval, 2.3-9.1) in proximal third fractures and 2.4 times greater (95% confidence interval, 1.5-3.9) in proximal half fractures compared with their more distal counterparts. CONCLUSIONS: Given the impressive rate of failure of closed reduction and casting of proximal third radial shaft fractures, the treating orthopaedic surgeon should prudently consider all management options. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of Nonoperative Treatment of the Symptomatic Accessory Navicular in Pediatric Patients.

Background: Initial management of symptomatic accessory navicular in pediatric patients is nonoperative. However, efficacy of nonoperative treatment has not been studied or established. If nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, surgery could be offered as first line treatment. This study retrospectively reviewed outcomes of pediatric patients treated nonoperatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families. Methods: A retrospective analysis of pediatric patients diagnosed and treated nonoperatively for a symptomatic accessory navicular bone at Cincinnati Children's Hospital Medical Center between dates August 1st, 2006 and August 24th, 2016 was performed. Outcome measures consisted of complete pain relief, partial relief without operative intervention, or need for operative intervention. Radiographic imaging for each patient was also used to identify the type of accessory navicular and presence of concurrent pes planus. Results: A total of 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with majority females (78%). Type 2 accessory naviculae were most frequent (72.7%), with Type 1 and Type 3 in 9.7% and 17.4%, respectively. Average number of nonoperative trials was 2.1, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that experienced partial pain relief and did not require surgical intervention, and were recommended as needed (PRN) follow-up based on clinical improvement. Of those that achieved complete pain relief, the average length of non-operative treatment was 8.0 months. Conclusions: The results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families.Level of Evidence: III.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Foot Fracture Pearls and Pitfalls.

Although foot fractures are relatively rare in children, they deserve respect and attention because they may be associated with troublesome long-term consequences. These injuries are more common in adolescents and teenagers. In an epidemiological study in Britain (Cooper et al 2004), the incidence of pediatric foot fractures was 10.5 per 10,000 children occurring equally in boys and girls and peaking around 13 years of age. This article focuses on 5 fracture types which are at higher risk of complications in the pediatric and adolescent age group.

Infantile Supracondylar Humeral Fractures (Patients Less Than Two Years of Age): Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation.

BACKGROUND: The age range for supracondylar humeral fractures spans from 1 to 14 years of age; most published studies have analyzed patients as non-age-segregated cohorts. Some isolated studies focused on the upper age range, demonstrating a male predominance and more severe fractures. The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures at the low end of the age range (<2 years of age). METHODS: Patients <2 years of age were identified from surgical billing records. Pin constructs were categorized as lateral column-only fixation or medial and lateral column fixation. All patients were followed through fracture-healing. Substantial loss of reduction was defined as a Baumann angle that changed ≥10° between surgery and healing or as a lateral rotation percentage (i.e., Gordon index) of ≥50% at the time of healing. The Fisher exact test was used for statistical analysis. RESULTS: One hundred and three patients met our inclusion criteria. There were 69 female and 34 male patients (a 2:1 female-to-male ratio). Two patients did not have adequate follow-up radiographs. Of the 46 patients with bicolumnar fixation, 5 (11%) demonstrated loss of reduction compared with 20 (36%) of 55 patients with lateral column-only fixation. This difference between the groups was significant (p = 0.005). The group with lateral column-only fixation had 4.7-times-higher odds of loss of reduction (95% confidence interval, 1.6 to 13.8). A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004). CONCLUSIONS: Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was of the lateral column only. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Standardization of Care of Common Pediatric Fractures.

Distal radius fractures are the most common site of fracture in the pediatric population. Supracondylar humerus fractures are the most common pediatric elbow fracture. Although there is abundant literature discussing treatment and outcomes of these fractures, there is only emerging literature specifically discussing the variation in care among surgeons. There is need for standardization of these types of injuries to optimize the quality, safety, and value for patients. Quality improvement methodology differs from traditional research and is meant to be shared and used to implement changes quickly. This article discusses basic quality improvement methodology.

Complications of Pediatric Foot and Ankle Fractures.

Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.

Tarsal Coalition in Children.

Tarsal coalition (a congenital fibrous, cartilaginous, or bony connection between two bones) classically presents with recurrent ankle sprains or with insidious onset of a painful, stiff flatfoot. Flatfoot is a benign finding most of the time, but it is important to distinguish the rigid flatfoot from the flexible flatfoot. A patient with recurrent sprains of the ankle or a stiff flatfoot should be evaluated for a tarsal coalition. The key to making the diagnosis is careful examination for stiffness in the subtalar joint and appropriate imaging studies. Both nonoperative and operative measures can be used to treat this condition.