New Injury Patterns in Pediatric Supracondylar Fractures During COVID-19: Beds Are the New Monkey Bars.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic drastically altered children's activity patterns. Our goal was to investigate how COVID-19 affected demographics, injury characteristics, treatment patterns, follow-up, and outcomes in pediatric supracondylar humerus (SCH) fractures. METHODS: This was an Institutional Review Board-approved retrospective analysis of patients undergoing surgery for a SCH fracture from May to November 2019 (pre-COVID-19) and from May to November 2020 (during COVID-19) at 2 tertiary children's hospitals. Demographic information, injury characteristics, hospital course, and follow-up data were collected and compared. RESULTS: SCH fractures decreased by >50% from 2019 (149) to 2020 (72). Children in the 2020 cohort were younger (mean 5.2 y old) compared with 2019 (6.0 y old) ( P =0.019). Mechanism of injury was significantly different in 2020 ( P <0.001), as the proportion of trampoline and furniture fractures increased from 8% and 17% to 15% and 33%, respectively. The proportion of playground and monkey bar fractures decreased from 20% and 17% to 3% and 4%, respectively. Distribution of Gartland type and neurovascular injury rates were similar in 2019 and 2020 ( P =0.411 and 0.538). Time from emergency department admission to the operating room and duration of hospital admission were both unchanged from 2019 to 2020 ( P =0.864 and 0.363). The duration of postoperative follow-up in 2019 was 94.5 days compared with 72.8 days in 2020 ( P =0.122), as more pandemic patients were lost to follow up (22.5% vs. 35.2%, P =0.049). CONCLUSIONS: The demographics, mechanism of injury, and follow-up practices of pediatric SCH fractures changed significantly during the pandemic, likely because of school closures and lock-downs changing activity patterns. Different mechanisms of injury affected younger patients and reflected the new ways children played. Trampoline-related and furniture-related injuries overtook the classic playground falls as primary mechanism of injury. Despite the need for COVID-19 testing, there was no delay in time to the operating room. Hospitalization duration did not change, yet postoperative follow-up was shorter, and more patients were lost to follow up. Despite these stressors, outcomes remained excellent in most children. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

The Prevalence of Bullying Among Pediatric Orthopaedic Patients.

BACKGROUND: Bullying is destructive and pervasive. Although the literature suggests children with chronic health conditions are at higher risk of being bullied, there is minimal research regarding the prevalence of bullying among children with orthopaedic conditions. Our study aimed to assess the prevalence of bullying among pediatric orthopaedic outpatients and evaluate the association of orthopaedic conditions and use of orthopaedic devices with perceptions of bullying. METHODS: Patients in outpatient pediatric orthopaedic clinics, ages 10 to 17 and their parents were surveyed using the Child-Adolescent Bullying Scale-9. Basic demographic, information about the child's orthopaedic condition, and parent's perception of their child being subject to bullying were also collected. Children were asked if they had used any orthopaedic devices in the last 3 months, whether they were bullied because of their device, and if bullying affected their compliance with device use. The analysis utilized a t test or analysis of variance to compare mean Child-Adolescent Bullying Scale-9 scores across different groups. RESULTS: Among the 198 patients surveyed, 61% (N=121) perceived no-to-minimal exposure to bullying, 36% (N=72) moderate exposure, and 3% (N=5) severe exposure. Children ages 10 to 13 (N=100) and children ages 14 to 17 (N=98) reported similar rates of bullying (P=0.97). Higher rates of moderate to severe bullying were reported by patients with foot deformity (80%), multiple orthopaedic diagnoses (55%), chronic pain (39%), fracture/acute injury (37%), and scoliosis (33%). Moderate to severe bullying was reported by 37% of patients who wore a cast, 40% who wore a brace/orthotic, and 52% who used multiple orthopaedic devices. Parental concern that their child was being bullied was highly correlated with their child's bullying score (P=0.0002). CONCLUSIONS: More than one third of our pediatric orthopaedic outpatients (39%) experience moderate to severe levels of bullying, which is higher than the general population's reported rates of 20% to 35%. Exposure to bullying may be higher in certain diagnoses or with use of certain orthopaedic devices. Further research is needed to delineate who is at highest risk. LEVEL OF EVIDENCE: Level IV.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

BACKGROUND: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. PURPOSE: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. RESULTS: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). CONCLUSION: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Classification and Treatment of Pediatric Tibial Spine Fractures: Assessing Reliability Among a Tibial Spine Research Interest Group.

BACKGROUND: Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures. METHODS: Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively. RESULTS: Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)]. CONCLUSIONS: Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons. LEVEL OF EVIDENCE: Level III-diagnostic reliability study of nonconsecutive patients.

Orthopedic Injuries Associated with Hoverboard Use in Children: A Multi-center Analysis.

BACKGROUND: Since its release in 2015, the hoverboard has been associated with injuries in children and adolescents. However, its public health implications have yet to be explored in the orthopedic literature across multiple centers. PURPOSE/QUESTIONS: We sought to assess the nature of orthopedic injuries and the use of clinical resources related to the hoverboard at four high-volume, regional pediatric hospitals. METHODS: Departmental databases of emergency department (ED) consultations and urgent orthopedic clinic (UC) visits were queried for hoverboard injuries. A retrospective medical record review was performed for patients presenting over a 3-month period at four institutions. Data on demographics, injuries, clinical course, and resource use were analyzed. The frequency of hoverboard-related consultations was compared to those for monkey bar-related injuries at the primary study institution. RESULTS: Eighty-nine patients with orthopedic hoverboard injuries presented to the ED and/or UC in the study period. Hoverboard injuries represented 2.2% of orthopedic ED consultations at the primary institution, compared to 1.5% for monkey bar injuries. Sixty-nine out of 89 (77.5%) total injuries involved the upper extremity, including 47 (52.8%) distal radius fractures, the most common hoverboard-related diagnosis. All but one injury (97.8%) underwent radiography, and eight (9%) required surgery. No patients reported wearing protective gear at the time of their injury. CONCLUSIONS: Hoverboards were associated with a variety of pediatric orthopedic injuries and required the use of significant resources in the ED, UC, and operating room. These data may represent a starting point for further prospective multi-center studies and public health efforts toward prevention of hoverboard injuries.

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study.

BACKGROUND: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). PURPOSE: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. STUDY DESIGN: Cross-sectional study; level of evidence, 3. METHODS: We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. RESULTS: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P < .001). There was a higher rate of lateral meniscal tears (P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. CONCLUSION: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Incidence of Symptomatic Pulmonary Embolus and Deep Vein Thrombosis After Knee Arthroscopy in the Pediatric and Adolescent Population.

OBJECTIVE: The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) after pediatric knee arthroscopy is unknown. The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after knee arthroscopy in the pediatric and adolescent population in a high-volume center. DESIGN: Retrospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: All patients who underwent arthroscopy of the knee for a sports-related injury by 2 surgeons were reviewed. Chief complaint, past medical/surgical history, medications, procedure performed, intraoperative findings, intraoperative complications, and postoperative recovery were reviewed. The incidences of postoperative VTE within 30 days after the procedure were reviewed. RESULTS: Seven hundred forty-six (358 male and 388 female patients) knee arthroscopies performed from September 2011 to October 2016 by 2 pediatric orthopedic surgeons specializing in sports-related injuries were included. The average age was 15.2 ± 2.72 years. Five patients were suspected to have either DVT or PE postoperatively (0.67%). The overall incidence of symptomatic confirmed VTE after knee arthroscopic procedures was 0.27% (one DVT after a partial lateral meniscectomy and one PE after fixation of an osteochondral lesion). CONCLUSIONS: The incidence of VTE after pediatric sports medicine knee arthroscopies is low, 0.27%. Patients who present with calf swelling or pain, chest pain, or shortness of breath after arthroscopic surgery should be examined closely. LEVEL OF EVIDENCE: Level III.

Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at controlling pain in children, especially in the treatment of fractures. Adult animal and adult clinical studies demonstrate conflicting evidence for the inhibitory relationship between NSAIDs and fracture healing. Published pediatric orthopaedic clinical studies do not demonstrate an inhibitory effect of ketorolac on bone healing. Little is known about the effects of any NSAID on bone formation in juvenile animals. This study investigates the effects of the NSAID ketorolac on fracture healing in a juvenile rat model. METHODS: Unilateral surgically induced and stabilized tibial shaft fractures were created in 45 juvenile (3 to 4 wk old) male Sprague-Dawley rats. Either ketorolac (5 mg/kg; n=24) or saline (0.9% normal saline; n=21) was then administered to the rats 6 d/wk by intraperitoneal injections. Animals were then randomly assigned into time groups and euthanized at 7 days (n=8 ketorolac, n=7 saline), 14 days (n=8 ketorolac, n=7 saline), or 21 days (n=8 ketorolac, n=7 saline) postfracture. Biomechanical analysis was performed using a custom-designed 4-point bending loading apparatus. Statistics for tibial stiffness and strength data were performed using software package Systat 11. Specimens were also evaluated histologically using hematoxylin and eosin staining. RESULTS: Strength and stiffness of all fractured tibiae increased over time from day 7 to day 21 regardless of treatment type. No statistical difference was found between the fractured tibiae strength or stiffness in the ketorolac or control-treated specimens at the same time point. In addition, the quality of the fracture callus was similar in both groups at each of the time points. CONCLUSIONS: In this study of a juvenile rat model with a stabilized tibia fracture, fracture callus strength, stiffness, and histologic characteristics were not affected by the administration of ketorolac during the first 21 days of fracture healing. CLINICAL RELEVANCE: The absence of inhibitory effects of ketorolac on early juvenile rat fracture healing supports the clinical practice of utilizing NSAIDs for analgesia in children with long bone fractures.

Premixed antibiotic bone cement: an in vitro comparison of antimicrobial efficacy.

After Food and Drug Administration (FDA) approval of premixed antibiotic bone cements (polymethylmethacrylate [PMMA]), these products are being used with increasing frequency during revision and primary hip and knee arthroplasties. To date, no studies have compared the antimicrobial efficacy of more than 2 products directly. Using a 7-day modified Kirby-Bauer assay, we assessed the in vitro antibacterial properties of 5 FDA-approved, commercially available antibiotic PMMAs. Significant differences in antimicrobial activity were noted among the antibiotic PMMA products included in this investigation. Antibacterial activity of all products tested was greatest on day 1 and rapidly diminished thereafter. Results of this investigation suggest that the antibacterial efficacies of premixed antibiotic PMMA products are not equivalent.