New Classification for Pediatric Proximal Fifth Metatarsal Fractures.

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared.

Pediatric Diving-Related Injuries in Swimming Pools Presenting to US Emergency Departments: 2008-2020.

OBJECTIVES: Recreational swimming/diving is among the most common physical activities in US children and a significant cause of morbidity across the United States. This study updates the national epidemiology of diving-related injuries. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance System database was queried for patients aged 0 to 19 from 2008 to 2020 who presented to any of the 100 National Electronic Injury Surveillance System-participating emergency departments for a diving-related injury. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives. RESULTS: A total of 1202 cases were identified for analysis corresponding to a total national estimate of 37,387 diving related injuries during the period from 2008 to 2020 and a national incidence of 3.6 injuries per 100,000 population. Males accounted for 64% of injuries. The average yearly incidences of injury in the 10 to 14 and 15 to 19 age groups were identical at 5.8 per 100,000. Contact with the diving board or platform was the most common cause of injury (34%). Diving backwards or attempting a flip or handstand dive were associated with increased odds of sustaining an injury resulting from contact with the diving board or platform (odds ratio, 16.0 and 6.9, respectively). In 2020, the incidence of diving-related injury fell to 1.6 per 100,000 population. CONCLUSIONS: Diving injuries are common in children and adolescents, especially in boys aged 10 to 19. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

A Comparison of Motorized and Nonmotorized Scooter Injuries in Pediatric Patients Seen in US Emergency Departments.

OBJECTIVES: We sought to characterize and compare trends in pediatric injuries sustained on motorized and nonmotorized scooters across the United States, to assess the use of safety equipment in children presenting with scooter-related injuries, and provide strategies for injury prevention. METHODS: The National Electronic Injury Surveillance System was queried for motorized and nonmotorized scooter-related pediatric injuries from 2014 to 2018 in patients ages 6 to 12 years. Patient demographics, diagnosis, injury location, and narrative of the incident were collected. Bivariate and regression analyses were used to determine demographic and social associations of injury characteristics. RESULTS: An estimated 146,000 (11,452 motorized and 134,548 nonmotorized) injuries occurred in children ages 6 to 12 years over the 5 years. Three of 4 injuries occurred in children younger than 10 years, and most injuries occurred in males (56%).From 2014 to 2018, the nationwide estimated incidence of motorized scooter injuries increased by 112.1%, while that of nonmotorized scooter injuries decreased by 40.3%.Upper extremity injuries were most common with nonmotorized scooters (44.4% of all injuries), while lower extremity injuries were most common with motorized scooters (39.5% of all injuries). Head and neck injuries accounted for 27.4% of nonmotorized scooter injuries and 23.4% of motorized scooter injuries. The number of concussions in motorized scooters increased from 0.4% in 2014 to 2.7% in 2018, while concussions in nonmotorized scooters decreased from 3.5% to 2.7%. Helmets were mentioned in the medical record in 6.6% of the cases. Of these, 60.5% reported no use of helmet at the time of injury. CONCLUSIONS: From 2014 to 2018, the number of motorized scooter injuries increased by 112.1% in the pediatric population ages 6 to 12 years, whereas nonmotorized scooter injuries decreased by 40.3%. In more than 60% of the cases that mentioned a helmet, the child injured was recorded as not wearing a helmet. The rise in pediatric injuries associated with motorized scooters in contrast with the reduction of injuries associated with nonmotorized scooters highlights the need for novel public health policies and interventions promoting helmet use with motorized scooters in the pediatric population.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19.

CONTEXT: The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004-2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19. OBJECTIVE: Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period. DESIGN: Retrospective cohort study. SETTING: This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016-June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic. PATIENTS OR OTHER PARTICIPANTS: Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified. MAIN OUTCOME MEASURE(S): Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses. RESULTS: A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant. CONCLUSIONS: Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

Can Rapid Progression in Nonambulatory Cerebral Palsy Scoliosis Be Predicted Using Humeral Head Ossification?

BACKGROUND: Patients with cerebral palsy scoliosis (CPS) experience higher complication rates compared with idiopathic scoliosis and often present for surgery with larger curves. Prediction of an inflection point for rapid deformity progression has proven difficult. A proximal humerus-based skeletal maturity staging system (HS) has been recently validated and is commonly visible on the posteroanterior radiograph. The authors hypothesize that this system can be used to identify a period at which CPS may progress rapidly, perhaps facilitating discussion of timely surgical intervention. METHODS: A retrospective review was conducted for nonambulatory pediatric patients with CPS who presented between 2009 and 2018 at our institution. All patients were considered for inclusion regardless of operative or nonoperative management. Patients who were skeletally mature at initial evaluation or had prior spine surgery were excluded. The authors analyzed radiographs in each HS available. Survival was calculated for cutoffs of 60 and 70 degrees (numbers found to increase intraoperative and postoperative complications for CPS). RESULTS: Eighty-six patients with CPS were identified (54 male individuals). Major curves increased significantly between HS 1 and 2 (27.7 to 46.6 degrees, P=0.009) and HS 3 and 4 (53.1 to 67.9 degrees, P=0.023). The proportion of curves ≥70 degrees were significantly different between HS (P<0.001), with the greatest increase between HS 3 and 4 (24% to 51%; ≥70 degrees). The largest drop in the 60/70-degree survival curves was between HS 3 and 4. In a subanalysis, 69% of patients with curves ≥40 degrees but <70 degrees in stage 3 would progress ≥70 degrees by stage 4. CONCLUSIONS: Identifying a period of rapid curve progression may guide surgical planning before CPS curves become large, stiff, and more difficult to fix. Our findings suggest that humeral skeletal maturity staging is a valuable decision-making tool in neuromuscular scoliosis, with the HS 3 to 4 transition representing the time of the greatest risk of progression. Consider a surgical discussion or shortened follow-up interval for patients with CPS with curves ≥40 degrees who are HS 3. LEVEL OF EVIDENCE: Level II.

Characteristics and Hospital Costs of Spica Cast Treatment of Non-accidental-related Diaphyseal Femoral Fractures in Children Before Walking Age.

BACKGROUND: Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures. METHODS: We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed. RESULTS: Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P<0.001). Overall consumer price index-adjusted hospital costs were $24,726 higher for NAT group compared with AT group (P=0.024), with costs of laboratory workup, radiology, and nonorthopaedic physician fees being the top 3 components contributing to the increased costs. CONCLUSIONS: The overall incidence of NAT was 46.6% in children presenting with femoral fracture under 1 year of age. The overall hospital cost of treating fractures in the NAT group was 1.5 times higher than the AT group, with imaging charges the most significant contributor to cost difference. LEVEL OF EVIDENCE: Level III-retrospective review.

Expert Consensus for Early Onset Scoliosis Surgery.

BACKGROUND: Despite a validated classification system, high-quality multicenter research databases (CSSG/GSSG), and a recent proliferation in publications, early-onset scoliosis (EOS) surgeons have no consensus on standards for surgical treatment. The 21st-century revolution in EOS care has only accelerated, with the arrival of a classification system, magnetically controlled growing rod, nusinersen, and improved nonoperative care (Mehta or Risser casting and compliance-monitored braces). This dizzying pace of change may have outstripped our ability to develop best-practice standards for EOS surgical indications. To learn where consensus is best (and worst) at this moment, we surveyed EOS world thought-leaders on a collection of representative cases. METHODS: A 6-case survey was constructed and sent to 20 EOS world thought-leaders. The cases were selected to be representative of the major treatment categories: idiopathic, neuromuscular, syndromic, congenital, thoracic dysplasia, and spinal muscular atrophy (specifically to assess the impact of nusinersen and parasol deformity on surgical planning). Respondents were queried regarding treatment with specific attention to instrumentation and construct when surgery was selected. Responses regarding surgical timing and technique were analyzed for consensus (defined as >80%). χ analysis was performed to evaluate for differences in treatment preferences based on years of experience. RESULTS: The survey response was 100%. Clinical experience ranged from 8 to 40 years (average 23.9 y). There was no consensus on any case. The greatest variability was on the congenital case; the closest to consensus was on the spinal muscular atrophy case. Three or more approaches were selected for all 6 cases; >4 approaches were selected for 5 cases. There is a trend towards screw fixation for proximal anchors. The management of thoracic dysplasia and parasol deformity is far from consensus. CONCLUSION: The lack of consensus for surgical treatment of 6 representative EOS cases demands a renewed effort and commitment to develop best-practice guidelines based on multicenter outcome data. LEVEL OF EVIDENCE: Level V-Expert Opinion.