Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome.

BACKGROUND: Forefoot fractures account for 6% to 10% of fractures in children, and although the majority heals with supportive treatment, complications may lead to pain and disability. No previous study in children has evaluated complication risk in the emergency department based on initial assessment characteristics. STUDY OBJECTIVES: The study aim was to identify the radiological and clinical variables that increase the complication rate of pediatric forefoot fractures. This may help emergency physicians refer patients who require more thorough follow-up or surgical intervention. METHODS: We evaluated 497 forefoot fractures on initial presentation to a pediatric emergency department at the Children's Hospital at London Health Science Centre over a 6-year period. We collected variables such as degree of angulation, displacement, number of concurrent fractures, and demographic data such as age and sex. We then determined the variables associated with complications by reviewing each patient's chart. RESULTS: Overall, there was a 6.4% complication rate. Analysis identified sex as an important predictor of complications. Females, although representing approximately one third of the sample, represented nearly two thirds of the cases with complicated outcomes (P = 0.001; odds ratio [OR], 4.67). Increased number of fractures was also significant (P = 0.01; OR, 2.41) as was increasing age (P = 0.01; OR, 1.17) and patients who chose to return to the emergency department (P < 0.05; OR, 5.282). Lateral angulation/displacement and anteroposterior angulation/displacement were not associated with increased complications. CONCLUSION: Identifying features, such as female sex, increasing age, multiple fractures, and return to emergency departments for repeat visits, may help guide the emergency physician on whom to refer for specialized care.

High reward makes items easier to remember, but harder to bind to a new temporal context.

Learning through reward is central to adaptive behavior. Indeed, items are remembered better if they are experienced while participants expect a reward, and people can deliberately prioritize memory for high- over low-valued items. Do memory advantages for high-valued items only emerge after deliberate prioritization in encoding? Or, do reward-based memory enhancements also apply to unrewarded memory tests and to implicit memory? First, we tested for a high-value memory advantage in unrewarded implicit- and explicit-tests (Experiment 1). Participants first learned high or low-reward values of 36 words, followed by unrewarded lexical decision and free-recall tests. High-value words were judged faster in lexical decision, and more often recalled in free recall. These two memory advantages for high-value words were negatively correlated suggesting at least two mechanisms by which reward value can influence later item-memorability. The ease with which the values were originally acquired explained the negative correlation: people who learned values earlier showed reward effects in implicit memory whereas people who learned values later showed reward effects in explicit memory. We then asked whether a high-value advantage would persist if trained items were linked to a new context (Experiments 2a and 2b). Following the same value training as in Experiment 1, participants learned lists composed of previously trained words mixed with new words, each followed by free recall. Thus, participants had to retrieve words only from the most recent list, irrespective of their values. High- and low-value words were recalled equally, but low-value words were recalled earlier than high-value words and high-value words were more often intruded (proactive interference). Thus, the high-value advantage holds for implicit- and explicit-memory, but comes with a side effect: High-value items are more difficult to relearn in a new context. Similar to emotional arousal, reward value can both enhance and impair memory.