Creatine supplementation in the pediatric and adolescent athlete-- A literature review.

Background: An increase in intra-muscular creatine through supplementation has been proposed as a strategy for improving muscle performance and recovery, with studies showing some benefit for adult athletes who rely on short, explosive movements. We reviewed and summarized the current literature on creatine supplementation in a pediatric and adolescent population. Methods: The databases PubMed and EMBASE were queried to identity articles related to the use of creatine supplementation in a healthy pediatric and adolescent population according to the guidelines established by PRISMA. The abstracts of all articles were reviewed to determine relevancy, with those meeting the pre-defined criteria included in the final review. Results: A combined total of 9393 articles were identified. Following application of filters and review of abstracts, 13 articles were found to meet criteria and were included in the final review. There was a total of 268 subjects across all studies, with mean age ranging from 11.5 to 18.2 years. More than 75% of the studies were randomized-controlled trials, and 85% involved either soccer players or swimmers. The overall quality of the studies was poor, and there were no consistent findings regarding creatine supplementation and improvements in athletic performance. No studies were designed to address the topic of safety. Conclusions: There is a gap in the study of the safety and efficacy of creatine supplementation in adolescents. Additional studies are needed to evaluate the effects of alterations in muscle composition on the growth, development, and performance of the developing athlete. Orthopedic providers should counsel their pediatric and adolescent patients on the current limitations in trying to assess the true risk and benefit of creatine supplementation for the aspiring athlete. Level of evidence: Review, III.

Surgical Hip Dislocation in Pediatric and Adolescent Patients.

LEVEL OF EVIDENCE: V, Expert opinion.

Outcomes of MPFL Reconstruction Utilizing a Quadriceps Turndown Technique in the Adolescent/Pediatric Population.

PURPOSE: Recurrent instability following a lateral patellar dislocation is a common indication for surgical intervention. Several surgical procedures are described in the literature to address recurrent patellar instability. Medial patellofemoral ligament (MPFL) reconstruction utilizing the quadriceps turndown technique attempts to restore medial stability. Results of the quadriceps turndown technique have previously only been reported in adult populations. The purpose of this study was to assess the safety, efficacy, and patient-reported outcomes following a quadriceps turndown MPFL reconstruction in the pediatric and adolescent population. METHODS: Records of all patients who underwent MPFL reconstruction using a quadriceps turndown technique between 2011 and 2018 were reviewed for demographics, risk factors, complications, mechanism of injury, and concomitant procedures. Return to activities of daily living (ADLs), return to presurgery level of sport, length of bracing, and recurrent instability were assessed with the administration of the Kujala Anterior Knee Pain Score. All analyses were completed using IBM SPSS Statistics 26. RESULTS: Thirty-six knees [14 female (39%), 22 male (61%)] from 34 patients met inclusion/exclusion criteria. The average follow-up length was 35.9±15.2 months. The average age was 16.3±1.8 years at the time of surgery. The average time for resumption of ADLs was 8.1±6.0 weeks after surgery. Ninety-four percent of patients returned to preinjury level of sport at an average of 23.6±12.0 weeks after surgery. Mean Kujala Anterior Knee Pain Score was 90.7±10.3. Female patients (P<0.001) reported significantly lower Kujala scores. Three patients (8%) experienced recurrent instability during ADLs and an additional 4 (11%) reported subjective feelings of instability only during sport or elevated activity. One knee required a return to the operating room for irrigation and debridement due to infection. CONCLUSION: This study demonstrates that the quadriceps turndown technique for MPFL reconstruction is a safe and effective procedure for the management of recurrent patellar instability in pediatric and adolescent patients. LEVEL OF EVIDENCE: Level III-therapeutic.

Probability analysis of sequential SCFE (PASS score).

PURPOSE: The study aimed to develop a scoring system based on clinical and radiological findings to predict the risk of a sequential slipped capital femoral epiphysis (SCFE). METHODS: Paediatric patients with unilateral SCFE and at least two years of radiographic follow-up were screened for inclusion. Medical records were reviewed for multiple variables including age, gender, body mass index (BMI), stability of SCFE, and time to sequential presentation. Radiographic analysis included triradiate physeal status, Risser staging, superior epiphyseal extension ratio (EER), posterior epiphyseal angle (PEA), posterior sloping angle (PSA) and slip severity. RESULTS: In total, 163 patients (88 male, 54%, 75 female, 46%) met inclusion criteria. Of those, 65 (40%) with a mean age of 11.9 ± 1.3 years developed sequential SCFE at a mean of 9.8 ± 6.4 months after the initial slip. Eight independent variables were statistically different (p < 0.05) between unilateral and sequential groups. Following multivariate analysis, Risser stage and triradiate status were no longer significant and did not influence the strength of the final model (overall area under the curve (AUC) = 0.954) and were consequently excluded. We developed the PASS score using three radiographic parameters using chosen cut-off values that were close to their maximized value and weighted the point value assigned to each parameter based on the strength of predictor. CONCLUSION: A PASS score of three or higher predicts a high probability of sequential SCFE with 95% confidence and may warrant prophylactic screw fixation. PASS score calculation can be used to predict a sequential SCFE and provide an objective method to determine the utility prophylactic screw fixation. LEVEL OF EVIDENCE: II.

Closed vs open reduction in developmental dysplasia of the hip: The short-term effect on acetabular remodeling.

BACKGROUND: This study aims to assess acetabular remodeling following closed vs, open hip reduction in children younger than 2 years of age. METHODS: Records of children with DDH, who underwent closed or open reduction, were reviewed. Acetabular index (AI) was measured on radiographs taken prior to reduction and on outcome radiographs taken at age 4 years. Radiographic outcomes were analyzed and residual dysplasia (outcome AI ≥ 30) degrees recorded. RESULTS: 42 hips had closed reduction; and 26 hips had open reduction. A higher percentage of hips treated with successful closed reduction, had outcome AI ≥ 30° (29% vs. 19% p = 0.387). Residual dysplasia was more common in IHDI-IV hips than IHDI-III hips for both groups. A higher incidence of AVN was seen in the open reduction group (13% vs. 7%; p = 0.43). CONCLUSION: In children with DDH under the age of two, open reduction with capsulorrhaphy may benefit acetabular remodeling more so than closed reduction despite maintenance of reduction. Although AVN remains a risk, higher remodeling might be expected with open reduction.

Treatment of Unstable Versus Stable Slipped Capital Femoral Epiphysis Using the Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure (open subcapital realignment via a surgical dislocation approach) has been shown to be a safe and effective way of treating acute, unstable slipped capital femoral epiphysis (SCFE). There is a paucity of literature comparing the modified Dunn procedure in stable SCFE. The purpose of this study was to compare acute, unstable versus chronic, stable SCFE managed with the modified Dunn procedure. METHODS: A retrospective chart review was performed on 44 skeletally immature patients who underwent the modified Dunn procedure for SCFE. Patients were divided into stable or unstable based on clinical presentation and intraoperative findings. Demographics, radiographic measurements, and complications were recorded and compared. χ and t tests were used to compare variables. RESULTS: In total, 31 consecutive hips (29 patients) with acute, unstable slips, and 17 consecutive hips (15 patients) with chronic, stable slips were reviewed. Average age was 12.5 and 13.8 years for acute and chronic, respectively (P=0.05). Mean follow-up was 27.9 months (unstable) and 35.5 months (stable). Average postoperative Southwick angle was 14.2 degrees; (unstable) and 25.3 degrees (stable) (P=0.001). Greater trochanteric height averaged 6.2 mm below the center of the femoral head in the acute group and 6.2 mm above center in the chronic group (P<0.001). Average femoral neck length measured 34.1 mm (unstable) and 27.1 mm (stable) (P<0.001). Two patients (6%) developed avascular necrosis (AVN) in the unstable group, with 5 patients (29.4%) in the stable group (P=0.027). All patients with hip instability (N=3) developed AVN. CONCLUSIONS: Although both acute, unstable and chronic, stable SCFE can be successfully treated with the modified Dunn procedure, the complication rate is statistically higher in patients with stable SCFE, specifically both AVN rate and postoperative instability. In addition, it is more difficult to establish normal anatomic indexes with regard to greater trochanteric height and femoral neck length. This procedure has great utility in the correction of the anatomic deformity associated with SCFE, but should be used with caution in patients with chronic, stable SCFE. LEVEL OF EVIDENCE: Level III-retrospective review.

Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. METHODS: Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, α angle, greater trochanteric height, and femoral neck length. RESULTS: Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, +19 to -9.4 degrees) (SD, 7.2), α angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5 mm below the center of femoral head (-17.5 to +25 mm), and mean femoral neck length difference measured -7.75 mm (range, -1.8 to -18.6 mm). CONCLUSIONS: A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest follow-up. Radiographs showed restoration of the slip angle, α angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. LEVEL OF EVIDENCE: Level III-retrospective review.

A Quality Improvement Initiative Reduces Cast Complications in a Pediatric Hospital.

BACKGROUND: Casts, while frequently used as routine treatment in pediatric orthopaedic practice, are not without complications. At our large tertiary care pediatric hospital, the baseline rate of all casting complications was 5.6 complications per 1000 casts applied (0.56%). We tested the hypothesis that we could use quality improvement (QI) methodology to decrease the overall cast complication rate and improve patient care. METHODS: We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act cycles, to decrease our cast complication rate. A resident casting education program was developed with a competency "checklist" to ensure that casts are applied, bivalved, and removed in a safe and standardized manner to prevent patient harm. AquaCast Saw Stop Protective Strips were required to be applied with every cast application. A review of our facility's processes and procedures determined adequate measures were in place to effectively manage inventory and maintenance of cast-saw blades. RESULTS: With the multimodal QI intervention, our cast complication rate was reduced to 1.61 complications per 1000 applications, a >90% improvement. CONCLUSIONS: Implementation of QI concepts to perform a QI initiative resulted in a shift toward fewer cast complications, leading to overall improved patient care at a large tertiary pediatric hospital. LEVEL OF EVIDENCE: Level II-prospective cohort study.

Management of foot and ankle injuries in pediatric and adolescent athletes: a narrative review.

In this review, we focus on the treatment of injuries to the foot and ankle in the adolescent athlete. While many injuries in the adolescent foot and ankle are similar to or overlap with their counterparts in the adult population, the anatomy of the adolescent ankle, especially the presence of growth plates, results in different injury patterns in many cases and calls for specific management approaches. We discuss the unique anatomy of the pediatric patient as well as the diagnostic evaluation and treatment of common injuries in the young athlete.

A prospective, double-blinded, randomized comparison of ultrasound-guided femoral nerve block with lateral femoral cutaneous nerve block versus standard anesthetic management for pain control during and after traumatic femur fracture repair in the pediatric population.

BACKGROUND: Traumatic injury of the femur resulting in femoral fracture may result in significant postoperative pain. As with other causes of acute pain, regional anesthesia may offer a benefit over conventional therapy with intravenous opioids. This study prospectively assesses the effects of femoral nerve blockade with a lateral femoral cutaneous nerve block (FN-LFCN) on intraoperative anesthetic requirements, postoperative pain scores, and opioid requirements. MATERIALS AND METHODS: Seventeen pediatric patients (age 2-18 years) undergoing surgical repair of a traumatic femur fracture fulfilled the study criteria and were randomly assigned to general anesthesia with either an FN-LFCN block (n = 10) or intravenous opioids (n = 7). All patients received a general anesthetic with isoflurane for maintenance anesthesia during the surgical repair of the femur fracture. Patients randomized to the FN-LFCN block group received ultrasound-guided nerve blockade using ropivacaine (0.2%/0.5% based on patient weight). At the conclusion of surgery, the airway device was removed once tracheal extubation criteria were achieved, and patients were transported to the post-anesthesia care unit (PACU) for recovery and assessment of pain by a blinded study nurse. RESULTS: The final study cohort included 17 patients (n = 10 for FN-LFCN block group; n = 7 for the intravenous opioid group). Although the median of the maximum postoperative pain scores in the regional group was 0, this did not reach statistical significance when compared to the median pain score of 3 in the intravenous opioid group. Likewise, no difference between the two groups was noted when comparing intraoperative anesthetic requirements, opioid requirements (intraoperative, in the post-anesthesia recovery room, and in the inpatient ward), and the time to first opioid requirement postoperatively in the inpatient ward. CONCLUSION: This prospective, randomized, double-blinded study failed to demonstrate a clear benefit of regional anesthesia over intravenous opioids intraoperatively and postoperatively during repair of femoral shaft fractures in the pediatric population.

Epidemiological Patterns of Initial and Subsequent Injuries in Collegiate Football Athletes.

BACKGROUND: A body of epidemiological studies has examined football injuries and associated risk factors among collegiate athletes. However, few existing studies specifically analyzed injury risk in terms of initial or subsequent injuries. PURPOSE: To determine athlete-exposures (AEs) and rates of initial and subsequent injury among collegiate football athletes. STUDY DESIGN: Descriptive epidemiological study. METHODS: Injury and exposure data collected from collegiate football players from two Division I universities (2007-2011) were analyzed. Rate of initial injury was calculated as the number of initial injuries divided by the total number of AEs for initial injuries, while the rate for subsequent injury was calculated as the number of subsequent injuries divided by the total number of AEs for subsequent injury. Poisson regression was used to determine injury rate ratio (subsequent vs initial injury), with adjustment for other covariates. RESULTS: The total AEs during the study period were 67,564, resulting in an overall injury rate of 35.2 per 10,000 AEs. Rates for initial and subsequent injuries were 31.7 and 45.3 per 10,000 AEs, respectively, with a rate ratio (RR) of 1.4 for rate of subsequent injury vs rate of initial injury (95% CI, 1.1-1.9). Rate of injury appeared to increase with each successive injury. RR during games was 1.8 (95% CI, 1.1-3.0). The rate of subsequent injuries to the head, neck, and face was 10.9 per 10,000 AEs, nearly double the rate of initial injuries to the same sites (RR = 2.0; 95% CI, 1.1-3.5). For wide receivers, the rate of subsequent injuries was 2.2 times the rate of initial injuries (95% CI, 1.3-3.8), and for defensive linemen, the rate of subsequent injuries was 2.1 times the rate of initial injuries (95% CI, 1.1-3.9). CONCLUSION: The method used in this study allows for a more accurate determination of injury risk among football players who have already been injured at least once. Further research is warranted to better identify which specific factors contribute to this increased risk for subsequent injury.

Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis.

BACKGROUND: The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE. METHODS: Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis. RESULTS: A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup. CONCLUSIONS: Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Ankle Injuries in the Pediatric Athlete.

Foot and ankle injuries are the second most common reason for young athletes to present to a primary care physician, and account for up to 30% of visits to sports medicine clinics in this population. Heightened performance expectations placed on today's young athletes have led to intense training and competition demands. With increasing rates of sport participation among children and adolescents, it is important for treating physicians to have an understanding of the evaluation and management of ankle injuries seen in the pediatric athlete. In treating young athletes it is important to keep in mind the unique developmental and anatomic differences between the skeletally mature and skeletally immature ankle. These differences predispose young athletes to unique injuries not seen in adults. These include injuries that result from congenital or developmental variations, acute injuries, and overuse type injuries.

Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared With Intramedullary Nailing.

This study compared the radiographic and clinical outcomes of pediatric diaphyseal femur fractures treated by submuscular plating, flexible retrograde intramedullary nailing, or rigid antegrade intramedullary nailing with a trochanteric entry point in skeletally immature patients who were 8 years and older. A retrospective review was conducted of skeletally immature patients 8 years and older who were treated for femur fracture with submuscular plating, flexible intramedullary nailing, or rigid intramedullary nailing from 2001 to 2014 with a minimum 12-week follow-up. Treatment outcomes were compared for statistical significance, including time to union, malunion, nonunion, heterotopic ossification, avascular necrosis, time to full weight bearing, limb length discrepancy, residual limp, painful hardware, and infection. The study identified 198 femur fractures in 196 patients (mean age, 11.9 years). Each femur fracture was treated with submuscular plating (35), flexible intramedullary nailing (61), or rigid intramedullary nailing (102). Mean follow-up across the cohort was 48 weeks, ranging from 12 to 225 weeks. Flexible nailing was associated with an increased incidence of malunion (P<.0001) and hardware irritation (P=.0204) and longer time to full weight bearing (P=.0018). Rigid nailing was associated with an increased incidence of limp at 12-week followup (P=.0412). Additionally, 23.5% of patients who were treated with rigid nailing had heterotopic ossification. Of all surgical methods, submuscular plating allowed for the most rapid return to full weight bearing (mean, 7 weeks) and offered the fastest healing rate (mean, 6 weeks). Submuscular plating resulted in faster times to union and full weight bearing, with minimal complication rates. Rigid intramedullary nailing with trochanteric entry resulted in a lower incidence of malunion and hardware-related complications; however, these patients had an increased incidence of heterotopic ossification and residual limp postoperatively. Flexible retrograde intramedullary nailing resulted in the highest rates of malunion and hardware irritation and the longest time to full weight bearing. [Orthopedics. 2016; 39(6):353-358.].

Bridge Plating Length-Unstable Pediatric Femoral Shaft Fractures.

The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.

Standardization of patellofemoral morphology in the pediatric knee.

BACKGROUND: Our understanding of osseous morphology and pathology of the patellofemoral joint continues to improve with the use of magnetic resonance imaging (MRI), but a paucity of data currently exists in the pediatric population. OBJECTIVE: We aim to formulate a reproducible means of quantitative assessment of patellofemoral morphology in children using MRI and to describe morphological changes based on sex and age. MATERIALS AND METHODS: We identified 414 children presenting between 2002 and 2014 who obtained a knee MRI to evaluate for knee pain or clinically suspected knee pathology. After application of inclusion criteria, 144 "normal" MRIs in 131 children (71 boys, 60 girls) were included in the analysis. The following MRI measurements were recorded: lateral trochlear inclination, trochlear facet asymmetry, trochlear depth, tibial tuberosity-trochlear groove distance, sulcus angle and patellar height ratio. To assess intraobserver reliability, measurements in 30 randomly selected children were repeated. Differences between patient age and sex were assessed using independent t-tests and adjusted regression analysis. RESULTS: All recorded measurements had strong to very strong inter- and intraobserver reliability: lateral trochlear inclination (0.91/0.82), trochlear facet asymmetry (0.81/0.83), trochlear depth (0.83/0.90), tibial tuberosity-trochlear groove distance (0.97/0.87), sulcus angle (0.84/0.78) and patellar height ratio (0.96/0.83). When age and sex were mutually adjusted, statistically significant differences between males and females were observed in trochlear depth (P = 0.0084) and patellar height ratio (P = 0.0035). However, statistically significant age differences were found on all measurements except for lateral trochlear inclination. As expected, mean measurement values approached adult norms throughout skeletal maturation suggestive of age-dependent patellofemoral maturation. CONCLUSION: Our data verify the development of patellofemoral morphology with advancing age. We found that six of the most commonly used patellofemoral measurements in adults can be accurately reproduced regardless of age.

Incidence of Hip Dysplasia Associated With Bladder Exstrophy.

BACKGROUND: Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients. METHODS: We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available. RESULTS: In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y). CONCLUSIONS: We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions. LEVEL OF EVIDENCE: Level III-retrospective study.

Traumatic, Posterior Pediatric Hip Dislocations With Associated Posterior Labrum Osteochondral Avulsion: Recognizing the Acetabular "Fleck" Sign.

BACKGROUND: Traumatic dislocation of the hip is uncommon in the pediatric population. Concentric reduction is usually achieved by closed means. Open reduction may be needed if there is femoral head fracture, incarcerated fragment, or incomplete reduction due to soft tissue entrapment. We present a series of 10 patients who sustained a posterior hip dislocation or subluxation with associated osteochondral avulsion of the posterior labrum. During surgery they were noted to have a labral injury pattern not previously recognized. Such treatment was dictated by postreduction advanced imaging, which revealed a consistent acetabular "fleck" sign indicative of this labral injury, which has not been previously described in literature. METHODS: We performed a retrospective case review of patients with traumatic posterior hip dislocation/subluxation, treated operatively for a suspected associated labral tear and fractures. RESULTS: Ten patients (2 girls and 8 boys) were identified. Average age was 12.7 years. Eight patients had postreduction computed tomography scans, which revealed a posterior acetabular wall "fleck" sign, suggestive of osteochondral injury. The small bony fragment was consistently displaced at least 2 to 3 mm in all patients with majority of the posterior wall remaining intact. Closed reduction was felt to be congruent in 7 of the 10 patients. All patients were treated operatively for exploration and stabilization of the suspected posterior labrum pathology and associated injuries using a surgical hip dislocation. A consistent pattern of labral pathology was seen in all patients, with disruption of the posterior labrum from the superior 12 o'clock attachment to detachment at the inferior 6 o'clock location. Reattachment of the osteochondral labral avulsion was performed with suture anchors along the posterior rim, and the associated femoral head fractures were also addressed with internal fixation. Two patients had inadequate follow-up and were excluded, the average follow-up for the remaining 8 patients was 9.8 months (range, 6 to 26 mo). There were no findings of avascular necrosis in any of the 8 patients. CONCLUSIONS: Posterior hip dislocation in children may produce an acetabular "fleck" sign on advanced imaging, which in a stable, concentrically reduced hip has been treated without surgery in the past. Acetabular fleck sign may represent a near-complete avulsion of the posterior labrum as seen in our series. We recommend a high suspicion for this type of labral pathology and surgical repair when acetabular "fleck" sign is identified with hip subluxation or dislocation. Traumatic, posterior hip dislocations in young patients may be associated with significant labral pathology. Acetabular "fleck" sign on advanced imaging may predict such pathology. LEVEL OF EVIDENCE: IV, retrospective study.

Septic Arthritis in Infants Younger Than 3 Months: A Retrospective Review.

Septic arthritis in infants is rare and can be difficult to diagnose. This study reviewed a series of patients younger than 3 months to identify factors that may assist in early diagnosis and treatment. A query of records at a large Midwestern pediatric hospital (1994-2010) was performed to identify all patients younger than 3 months at the time of diagnosis. Analysis included birth history, joint involvement, physical examination findings, laboratory results, imaging results, method of treatment, and outcome. In 14 cases (11 boys, 3 girls; mean age at diagnosis, 42.2 days), complete records were available for review. Involved joints included the knee, hip, and shoulder. The most common findings on physical examination were decreased range of motion (100%), tenderness (100%), and swelling (71.4%). Mean temperature was 38.5°C. Mean white blood cell count was 18.5 K/µL, mean erythrocyte sedimentation rate was 48.9 mm/h, and mean C-reactive protein level was 6.1 mg/dL. More than half (57.1%) of joint aspirates grew positive cultures, and 41.7% of blood cultures had positive results. Causative organisms were group B streptococcus, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Salmonella enterica, and Candida albicans. The most common physical examination findings in infants younger than 3 months with septic arthritis include tenderness, decreased range of motion, and swelling. White blood cell count, C-reactive protein level, and erythrocyte sedimentation rate are likely to be elevated, but these findings should be used in combination with findings on physical examination and radiographic studies to aid in diagnosis.

Acute, unstable slipped capital femoral epiphysis with associated congenital coxa vara.

Slipped capital femoral epiphysis in patients younger than 10 years is rare and is often associated with some identifiable metabolic or endocrinologic abnormality. We present a case of a 5-year-old girl with an acute, unstable, severe slipped capital femoral epiphysis associated with congenital coxa vara and its surgical management. This association has not been described in previous literature. Surgical treatment is proposed and described.