A Rapid MRI Protocol for the Evaluation of Acute Pediatric Musculoskeletal Infections: Eliminating Contrast and Decreasing Anesthesia, Scan Time, and Hospital Length of Stay and Charges.

BACKGROUND: Acute musculoskeletal infection affects >1 in 6,000 children in the United States annually. Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of musculoskeletal infection, but it traditionally requires contrast and anesthesia for children, delaying management. A rapid MRI protocol involves MRI without anesthesia and with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to identify abscesses. We hypothesized that a rapid MRI protocol would improve imaging and treatment efficiency for pediatric patients undergoing musculoskeletal infection evaluation without substantially affecting accuracy. METHODS: This was a single-center, retrospective study of patients undergoing evaluation for musculoskeletal infection before (60 patients in the traditional cohort [TC]) and after (68 patients in the rapid cohort [RC]) implementation of the rapid MRI protocol. Sociodemographic and clinical variables were extracted from electronic health records, and statistical comparisons were performed. RESULTS: The anesthesia rates were 53% for the TC and 4% for the RC, and the contrast administration rates were 88% for the TC and 0% for the RC. The median time to MRI after ordering was 6.5 hours (95% confidence interval [CI], 5.0 to 8.6 hours) for the TC and 2.2 hours (95% CI, 1.4 to 3.6 hours) for the RC (p < 0.01). The median duration of MRI was 63.2 minutes (95% CI, 56.8 to 69.6 minutes) for the TC and 24.0 minutes (95% CI, 21.1 to 29.5 minutes) for the RC (p < 0.01). The median hospital length of stay was 5.3 days (95% CI, 3.7 to 6.9 days) for the TC and 3.7 days (95% CI, 1.9 to 4.1 days) for the RC (p < 0.01). The median hospital charges were $47,309 (95% CI, $39,137 to $58,769) for the TC and $32,824 (95% CI, $22,865 to $45,339) for the RC (p < 0.01). Only 2 positive cases of musculoskeletal infection in the RC were missed on the initial imaging, but these instances were not attributable to the rapid protocol itself. Although 10 of 68 rapid MRI scans resulted in nondiagnostic outcomes due to patient motion, only 6 of 68 required repeat MRI with anesthesia. CONCLUSIONS: In patients evaluated for musculoskeletal infection, the rapid MRI protocol eliminated contrast and minimized anesthesia while improving MRI access and decreased scan and interpretation times, hospital length of stay, and hospital charges. The rapid MRI protocol had high sensitivity for diagnosing musculoskeletal infection and a low rate of imaging failure. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Injury Patterns in Highly Specialized Youth Athletes: A Comparison of 2 Pathways to Specialization.

CONTEXT: Sport specialization, commonly defined as intensive year-round training in a single sport to the exclusion of other sports, has been associated with an increased risk for overuse injury. Two pathways to becoming highly specialized are recognized: (1) having only ever played 1 sport (exclusive highly specialized) and (2) quitting other sports to focus on a single sport (evolved highly specialized). Understanding the differences in injury patterns between these groups of highly specialized athletes will inform the development of injury-prevention strategies. OBJECTIVE: To compare the distribution of injury types (acute, overuse, serious overuse) among evolved highly specialized athletes, exclusive highly specialized athletes, and low-moderately specialized athletes. DESIGN: Cross-sectional study. SETTING: Tertiary care pediatric sports medicine clinic between January 2015 and April 2019. PATIENTS OR OTHER PARTICIPANTS: A total of 1171 patients (age = 12.01-17.83 years, 59.8% female) who played ≥1 organized sports, presented with a sport-related injury, and completed a sports participation survey. MAIN OUTCOME MEASURE(S): Distribution of injury types (acute, overuse, serious overuse). RESULTS: The percentage of injuries due to overuse was similar between the exclusive and evolved highly specialized athletes (59.2% versus 53.9%; P = .28). Compared with low-moderately specialized athletes, exclusive and evolved highly specialized athletes had a higher percentage of overuse injuries (45.3% versus 59.2% and 53.9%, respectively; P = .001). Multivariate analysis of the highly specialized groups revealed sport type to be a significant predictor of a higher percentage of injuries due to overuse, with individual-sport athletes having increased odds of sustaining an overuse injury compared with team-sport athletes (odds ratio = 1.95; 95% CI = 1.17, 3.24). CONCLUSIONS: The distribution of injury types was similar between evolved and exclusive highly specialized youth athletes, with both groups having a higher percentage of injuries due to overuse compared with low-moderately specialized athletes. Among highly specialized athletes, playing an individual sport was associated with a higher proportion of overuse injuries compared with playing a team sport.

The Effects of Injury Type on Health-Related Quality of Life in Youth Athletes: A Cross-Sectional Analysis.

OBJECTIVE: The relationship between health-related quality of life (HRQoL) and injury type has not been analyzed for young athletes. We hypothesized that there would be no difference in HRQoL between injured athletes, injured nonathletes, and normative data for healthy youth (NDHY) or among athletes with acute, overuse, or concussion injuries. DESIGN: Cross-sectional clinical cohort. SETTING: Primary care sports medicine clinics at 3 academic institutions. PARTICIPANTS: Patients aged 8 to 18 years presenting with injury. INDEPENDENT VARIABLES: Injury type and athletic participation. MAIN OUTCOME MEASURES: Health-related quality of life measured 1 month after injury through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 v2.0 assessed pain interference, peer relationships, depression, fatigue, anxiety, and mobility. One-way analysis of variance was performed with P values of <0.05 considered significant. Concussion Learning Assessment and School Survey (CLASS) evaluated academic performance. RESULTS: Three hundred fifty-seven patients (36% male), with average age of 14.2 years, completed HRQoL and CLASS surveys following injury. There were 196 overuse injuries (55%), 119 acute injuries (33%), and 42 concussions (12%). Ninety-four percent were athletes. Six percent were nonathletes; 90.5% of concussed patients reported grades worsening. Concussed athletes reported more fatigue (P = 0.008) compared with other injury types but no worse than NDHY. Athletes with overuse injuries had lower mobility (P = 0.005) than other injury types and NDHY. Patients with lower HRQoL were female, older age, or required surgery. No other domains had significant differences by injury type nor did HRQoL differ between the athletes, nonathletes, and NDHY. CONCLUSIONS: With the exception of injuries requiring surgery, HRQoL of injured young athletes was similar to NDHY in most domains.

Assessment of post-concussion emotional symptom load using PCSS and PROMIS instruments in pediatric patients.

OBJECTIVES: The purpose of this study is to evaluate the utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depressive symptom domains in conjunction with the Post-Concussion Symptom Scale (PCSS)for identifying pediatric patients with emotional symptoms following a concussion, and to identify predictors of higher emotional symptom loads. METHODS: We recruited English-speaking patients aged 8-17 years presenting to a tertiary-care concussion clinic from 2014 to 2018 (n = 458). Demographics and clinical data including PCSS, injury date, previous history of anxiety/depression, and Vestibular/Ocular-Motor Screen (VOMS) were collected from patients' electronic medical records. Participants completed surveys in the PROMISTM Pediatric Item Bank v1.1-Anxiety and Depressive Symptoms domains at their initial clinic visit. Multivariable linear regression identified predictors of higher emotional symptom loads. RESULTS: Overall, 425 (92.8%) reported ≥1 emotional symptom on either PROMIS or PCSS. Predictors of higher emotional symptom loads were abnormal VOMS, female sex, history of anxiety or depression, and longer time since injury. CONCLUSION: Our results suggest that adding PROMIS anxiety and depressive symptom surveys to pediatric concussion evaluations may identify more children with emotional symptoms, allowing clinicians to better direct post-concussion treatment and incorporate psychological support for patients if necessary. Future studies should examine whether earlier identification of emotional symptoms with these tools facilitates recovery and improves short- and/or long-term psychological outcomes in pediatric concussion.

Timeout? The Epidemiology of Pediatric Sports Injuries During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic resulted in closure of schools and playgrounds while requiring social distancing, changes that likely affected youth sports participation. The purpose of this study was to identify changes in the epidemiology of pediatric sports injuries during the COVID-19 pandemic. METHODS: This retrospective cohort study included patients between the ages of 4 and 18 years who presented to orthopaedic clinics within a single children's hospital network with an acute injury sustained during athletic activity between March 20, 2020, and June 3, 2020 (the strictest period of state-level shelter-in-place orders). These patients were compared with those within the same dates in 2018 and 2019. Chi square and Mann-Whitney U tests were used, as appropriate. RESULTS: Significantly less sports injuries were seen during the pandemic (n = 257) compared with the same dates in 2018 (n = 483) and 2019 (n = 444) despite more providers available in 2020 (P < 0.001). During the pandemic, patients with sports injuries were younger (median age 11 versus 13 years, P < 0.001) and had less delay in presentation (median 5 versus 11 days, P < 0.001). A higher proportion were White (66.9% versus 47.7%, P < 0.001), privately insured (63.4% versus 48.3%, P < 0.001), and seen at a nonurban location (63.4% versus 50.2%, P < 0.001). Most sports injuries during the pandemic were fractures (83.7%). Although 71.4% of all injuries in the prepandemic period occurred in the context of formal sports, only 15.2% were sustained in a formal athletic context in 2020 (P < 0.001). The frequency of surgical treatment was higher during the pandemic (14.8% versus 7.8%, P = 0.001), mainly because most of these injuries were fractures requiring surgical intervention. CONCLUSIONS: Fewer sports injuries were seen in the outpatient setting during the COVID-19 pandemic, and most of these injuries were fractures and occurred outside of organized sports settings. Patients were more likely to be White, privately insured, and seen at a nonurban location.

Rhythmic gymnasts' injuries in a pediatric sports medicine clinic in the United States: a 10-year retrospective chart review.

OBJECTIVES: Rhythmic gymnastics injuries have not been studied thoroughly especially in the United States. Existing research studies are predominantly from Europe or Canada or from more than 15 years ago. The purpose of our study was to provide an updated description of injury patterns among rhythmic gymnasts in the United States. METHODS: A retrospective chart review was conducted of 193 rhythmic gymnastics injuries in 79 females, ages 6-20. Patients were seen between January 2010 and March 2020 in a hospital-based pediatric sports medicine clinic. Gymnast demographics, injury locations, and injury types were collected as available. Descriptive and bivariate statistical analysis was performed using general linear mixed models. RESULTS: Our cohort had a mean age of 14.61 ± 2.61 years. Overuse injuries (76.7%) were more common than acute injuries (23.3%). The most common injury types were strain (20.7%), nonspecific pain (15.5%), and tendinitis/tenosynovitis (10.36%). The most frequently injured body regions were lower extremity (75.1%), followed by trunk/back (19.2%), upper extremity (4.7%), and head/neck (1.0%). The most common injured body parts were foot (24.9%), ankle (15.5%), knee (15.0%), lower back (14.0%), and hip (13.0%). General linear mixed models revealed that older age (p = 0.001) and higher competitive level (p = 0.016) were associated with a greater number of diagnoses. Gymnasts with foot injuries were older than gymnasts with ankle (p = 0.026), hip (p < 0.0001), and knee (p = 0.002) injuries. Gymnasts with higher BMI-for-age percentile were more likely to have acute injuries than overuse (p = 0.035). CONCLUSION: Our data showed that injuries among rhythmic gymnasts were most frequently located in the lower extremities, specifically the foot, followed by trunk/back. Additionally, the most frequent injury types were strains and nonspecific pain, and overuse was the most prevalent mechanism. Gymnasts with foot injuries were older than gymnasts with ankle, hip, and knee injuries. Higher BMI is a predictor of acute injuries.

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.