ATV-Related Trauma in the Pediatric Population.

BACKGROUND: All-terrain vehicles (ATVs) are prevalent in Appalachia and cause significant morbidity and mortality in the pediatric population. This study investigated the injury types and severity in pediatric patients over a 15-year period. METHODS: A retrospective chart review was performed on pediatric ATV-related traumas presenting to our institution from 2005 to 2020. Patients were divided into 3 age groups (0-7, 8-12, and 13-17 y) to evaluate differences in accident demographics, hospitalization, Glasgow Coma Scale, Injury Severity Score, substance use, characterization of orthopaedic and nonorthopaedic injuries, and procedures performed. RESULTS: Inclusion criteria were met by 802 patients. Males represented 71.7% (n=575) and females 28.3% (n=227); the mean age was 12.4 years. The majority (88.5%, n=710) of patients admitted following their accident had a mean stay length of 3.3 days. Of admissions, intensive care unit admission was required by 23.8%, n=191 (mean stay 4.0 d). There were 7 fatalities. The vast majority of accidents occurred between May and September (79.2%, n=635). In patients with documented helmet status, 45% (n=271) were helmeted. Roughly half of all patients (n=393) sustained a fracture (excluding fractures to the head), 370 sustained an injury to the head/face, 129 sustained intra-abdominal/intra-thoracic injuries, and 29 sustained injuries to all 3 systems. The most common fractures involved the forearm (n=98), femur (n=65), and spine (n=59). The most common open fractures were the tibia (n=12), humerus (n=8), and forearm (n=8). The oldest group was more likely than the middle or younger groups to sustain spine ( P <0.0001), pelvis ( P =0.0001), hand ( P =0.0089), and foot ( P =0.0487) fractures. Ethanol testing was positive in 5.0% (n=25) of the oldest group and cannabinoids were present in 6.8% (n=34). The youngest group was significantly more likely to sustain a fracture of the humerus than the middle or older groups ( P <0.0001). Orthopaedic surgical management was required in 24.4% (n=196) of patients. CONCLUSIONS: Pediatric ATV accidents present a significant source of morbidity and mortality. Further intervention is necessary to minimize pediatric ATV injuries. LEVEL OF EVIDENCE: Level IV-Retrospective Case Series.

Effect of State Legislation on Opioid Prescribing Practices After Surgery at a Pediatric Hospital.

OBJECTIVE: As abuse of prescription narcotics continues to create a growing healthcare crisis throughout the United States, states have passed legislation designed to alter narcotic prescribing habits. West Virginia State Bill 273 limited the quantity of narcotics practitioners were able to prescribe. Our objective was to determine the effect of this bill on narcotic prescribing practices for pediatric surgical patients. METHODS: A hospital-wide database at a pediatric trauma center was queried to identify all pediatric patients undergoing surgery between January 1, 2017 and December 9, 2019 and all medications prescribed to this cohort. Narcotic prescriptions written for these patients in the 2 months following surgery were isolated. The percent of patients receiving a postoperative narcotic prescription and the morphine milligram equivalents (MME) per prescription were compared before and after the law's implementation. RESULTS: The number of pediatric patients identified as having surgery in the study period was 10,176; 6069 were before the law passed and 4107 were after. The percentage of patients receiving a narcotic prescription was 46.0% before the law was passed, decreasing to 36.8% after the law (P < .0001). Adjusted for age, the average MME of each prescription before the law's implementation was 104.0, which decreased to 79.2 after the law (P < .0001). CONCLUSIONS: The amount of narcotic per prescription written for pediatric patients after surgery and the percentage of patients receiving a prescription decreased after West Virginia State Bill 273 was implemented. This law was associated with decreased narcotics written by providers, providing an example for future legislation targeting opioid prescribing and abuse.

Pain Medication Disposal Rates After Pediatric Surgery.

OBJECTIVES: To investigate prescription opiate usage, disposal rates, and methods of disposal after pediatric surgery. METHODS: This was a retrospective chart review of patients <18 years of age who underwent a surgical procedure at our institution and were given a postoperative opiate prescription between April 2017 and June 2018. A follow-up phone survey was conducted between 60 and 90 days postoperatively to ask about prescription opiate usage and disposal. RESULTS: A total of 290 patients with a mean age of 9.0 ± 4.7 years (62.8% male) met inclusion criteria. Sixty patients (20.7%) reported using all of their prescription opiate medication, whereas 230 patients (79.3%) did not use all of their pain medication. Of these 230 patients, 141 (61.3%) disposed of their leftover prescription opiates via flushing (56.4%), trash (28.6%), or take-back center (15.0%). At the time of phone survey between 60 and 90 days postoperatively, 88 patients (38.3%) still had leftover pain medication. By 7 days postoperatively, 234 of 290 patients (80.7%) had taken their last prescription opioid. CONCLUSIONS: In our study, 79.3% of patients were overprescribed opiate pain medication after pediatric surgery. Disposal rates at 60 to 90 days for leftover pain medication after pediatric surgery was just >60%. Pediatric patients are often overprescribed prescription opiates after surgery and typically only require a one-week supply of pain medication.

Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis.

BACKGROUND: Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. METHODS: Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. RESULTS: Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration. CONCLUSIONS: Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Treatment of an open medial tibiotalar dislocation with no associated fracture.

Tibiotalar dislocations without associated fractures are very uncommon in adults, and only a few studies have been published regarding this injury. More than 50% of these dislocations will be posteromedial, with a high incidence of open injuries, and 25% are pure posterior dislocations. In the present report, we discuss our experience and management of a medial tibiotalar dislocation with no associated fracture. In the present case, the patient was brought to the operating room on presentation to our facility and underwent irrigation and debridement with primary closure of his wound. He was immobilized postoperatively. The patient tolerated the operation well and did not sustain any postoperative complications. He was able to regain function of the injured extremity until he was lost to follow-up. Regarding treatment, the surgery should be speedy, gentle to the soft tissue, and with as little implanted material as possible. Although we do not advocate that our management and treatment of this injury become the standard, the present case provides a good example of some of the challenges often encountered when treating these injuries.