Improving Pediatric Radiography Patient Stress, Mood, and Parental Satisfaction Through Positive Environmental Distractions: A Randomized Control Trial.

UNLABELLED: To evaluate how a positive environmental distraction intervention impacted pediatric radiography patient behavioral stress-responses, mood states, and parental satisfaction. METHODS: Behavioral observation, rating scales, surveys on 182 pediatric patients and their parents randomly assigned to three positive distraction levels (minimum, light, light and animation). RESULTS: Under interventional conditions, patients exhibited less low-stress coping behaviors (ps<0.001-0.007) and more verbal behaviors indicating positive affect (p=0.003); parents more favorably rated environmental pleasantness (ps<0.001), sense of environmental control (ps=0.002), and willingness to return and recommend the facility (ps=0.001-0.005). CONCLUSION: The intervention improved pediatric radiography experience but needs further investigation in more stressful settings.

Submuscular locked plating of pediatric femur fractures.

Recent advances in plating technology for the pediatric femur fracture have demonstrated early mobilization of the extremity and early weight bearing. Submuscular techniques allow for minimal soft tissue disruption and provide a theoretical healing advantage. This article presents results of the treatment of pediatric femur fractures using a locked submuscular bridge plating technique. The authors reviewed 16 patients between 6 and 12 years of age who sustained a femoral shaft fracture treated with minimally invasive submuscular locked plating. Patients were followed for an average of 25 months and made full weight bearing within 6 weeks of surgery. All patients achieved radiographic and clinical union with an average time of 2.6 months. Range of motion of the knee and hip were equivalent to the contralateral extremity at 2.1 months. Average time of hardware removal was 11 months. Benefits of locked plating of pediatric femur fractures include high union rates, early weight bearing, early recovery of range of motion, and minimal complications.

Comparing the effectiveness of modified forearm and conventional minidose intravenous regional anesthesia for reduction of distal forearm fractures in children.

BACKGROUND: Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. METHODS: Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. RESULTS: Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. CONCLUSION: The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. LEVEL OF EVIDENCE: Level I, therapeutic study.

Healthy children with frequent fractures: how much evaluation is needed?

OBJECTIVE: We performed a case-control study to determine whether occult bone disease is associated with a history of frequent fractures in children. METHODS: Healthy children with > or = 2 incidences of low-energy fractures were recruited (n = 68). Children with no history of fractures served as control subjects (n = 57). Food logs, activity surveys, physical examinations, laboratory tests, and dual-energy radiographic absorptiometry were used. RESULTS: Bone mineral density z scores were significantly reduced in case subjects, compared with control subjects. Three case subjects (4.3%) and 1 control subject (1.8%) had bone mineral density z scores below the expected range. Of those 4 subjects, 2 had dairy avoidance and 2 had delayed puberty. An additional case subject had evidence of vitamin D deficiency. A significant number of subjects (20% of case subjects and 23% of control subjects) had idiopathic hypercalcuria, based on 24-hour urine collections. Among the case subjects, bone mineral density z scores were significantly lower for those with idiopathic hypercalcuria. Among the control subjects, the presence of idiopathic hypercalcuria did not affect bone mineral density. The case subjects with idiopathic hypercalcuria accounted for virtually all of the differences in bone mineral density between the case and control groups. Analysis of parathyroid hormone and 1,25-dihydroxy-vitamin D levels showed that children with frequent fractures and hypercalcuria had renal hypercalcuria, whereas children with no fractures and hypercalcuria had absorptive hypercalcuria. CONCLUSIONS: We identified a significant association between a history of frequent fractures and hypercalcuria in children. We propose that the appropriate screening evaluation for children who present with a history of frequent fractures consists of a dietary history targeted at calcium and vitamin D intakes, a physical examination to assess for pubertal delay, and urinary calcium concentration/creatinine ratio determination to assess for hypercalcuria. Children with abnormalities in this screening should undergo dual-energy radiographic absorptiometry and appropriate evaluation.

Remodeling of the proximal femur after varus osteotomy.

The purpose of this study was to measure the remodeling of the proximal femur after varus osteotomy and to determine the factors that may affect the degree of angular correction. In addition, we wanted to determine the degree of remodeling over time. One hundred nine varus proximal osteotomies were performed on 66 children with hip dysplasia. Neck-shaft angles were measured on preoperative, immediate postoperative, and follow-up radiographs. Remodeling of the proximal femur occurred after varus osteotomy as long as the physes of the proximal femur continued growing. Patients' remodeling varied widely; however, gender, ambulatory status, and original diagnosis had little effect on the magnitude of remodeling. Results from this study reinforce the need to follow patients with periodic hip radiographs until growth is complete.

Ossifying subperiosteal hematoma associated with neurofibromatosis type 1. Diagnostic hesitation: a case report and literature review.

We here in report a case of ossifying subperiosteal hematoma in a child with Neurofibromatosis Type I. The availability of an MRI and centers experience with the disease supported our delay in aggressive treatment of this expanding inflammatory mass.

Remodeling of the proximal femur after varus osteotomy in children with cerebral palsy.

The purpose of this study was to determine and measure the factors that affect the remodeling of the proximal femur after varus osteotomy in children with spastic cerebral palsy (CP). Seventy-five varus proximal osteotomies were performed on 44 children (26 females, 18 males) for hip dysplasia. Thirty-nine patients had spastic CP and five had spastic diplegia; 35 patients used a wheelchair for mobility and nine could walk. Mean age at time of surgery was 8 years (SD 4 years), range 2 years 6 months to 15 years. Preoperative, immediate postoperative, and follow-up (0 to 6 months, 6 months to <1 year, 1 year to <2 years, 2 years to <4 years, 4 years to <6 years, and 6 years to <8 years) radiographs were reviewed. Neck-shaft angles were measured. Correlations to examine the relationship between age at time of surgery and ambulatory status with postoperative changes in neck-shaft angles were reviewed. Remodeling of the proximal femur does occur after varus osteotomy as long as the physes of the proximal femur show growth potential. Remodeling was quite variable between patients: children younger than 4 years old at the time of surgery remodeled more than children who were older than 4 years. Ambulatory status has little effect on the magnitude of remodeling. This study reinforces the need to follow these patients with periodic hip radiographs until completion of growth.

Combined odontoid and jefferson fracture in a child: a case report.

STUDY DESIGN: A case of combined odontoid and Jefferson fracture is reported. OBJECTIVE: To alert spine physicians to the rare combination of an odontoid and Jefferson fracture in a child. METHODS: A 5-year old boy presented with neck pain and torticollis after falling on his head from a four-wheeler that had rolled over. A computed tomography scan confirmed a combined odontoid and Jefferson fracture. RESULTS: The child was successfully treated nonsurgically with a hard cervical orthosis. At this writing, the child clinically is asymptomatic 2 years after the injury. DISCUSSION: The fall on to the head caused the body weight to be transmitted to the atlas. The resulting force vector produced the classic Jefferson fracture of the atlas. As the atlas fracture spread with continued compressive and axial forces, tension was exerted on the alar ligaments (check ligaments), leading to the avulsion fracture of the odontoid. CONCLUSIONS: This is only the second reported case of a child with a combined Jefferson and odontoid fracture. This diagnosis should be considered in the evaluation of a child with neck pain and torticollis from a fall on the top of the head.