Safely Reducing Unnecessary Radiographs in Suspected Pediatric Musculoskeletal Injuries: A Multidisciplinary Developed Algorithm.

BACKGROUND: While radiographs are a critical component of diagnosing musculoskeletal (MSK) injuries, they are associated with radiation exposure, patient discomfort, and financial costs. Our study initiative was to develop a system to diagnose pediatric MSK injuries efficiently while minimizing unnecessary radiographs. METHODS: This was a quality improvement trial performed prospectively at a single level one trauma center. A multidisciplinary team with leaders from pediatric orthopedics, trauma surgery, emergency medicine, and radiology created an algorithm delineating which x-rays should be obtained for pediatric patients presenting with MSK injuries. The intervention was performed in the following 3 stages: stage 1: retrospective validation of the algorithm, stage 2: implementation of the algorithm, and stage 3: sustainability evaluation. Outcomes measured included number of extra radiographs per pediatric patient and any missed injuries. RESULTS: In stage 1, 295 patients presented to the pediatric emergency department with MSK injuries. A total of 2148 radiographs were obtained, with 801 not indicated per the protocol, for an average of 2.75 unnecessary radiographs per patient. No injuries would have been missed using the protocol. In stage 2, 472 patients had 2393 radiographs with 339 not indicated per protocol, averaging 0.72 unnecessary radiographs per patient, a significant reduction from stage 1 ( P < 0.001). There were no missed injuries identified on follow-up. In stage 3, improvement was sustained for the subsequent 8 months with an average of 0.34 unnecessary radiographs per patient ( P < 0.05). CONCLUSIONS: Sustained reduction of unnecessary radiation to pediatric patients with suspected MSK injuries was accomplished through the development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach, widespread education of pediatric providers, and standardized order sets improved buy-in and is generalizable to other institutions.Level of Evidence: III.

Biologic principles of minced cartilage implantation: a narrative review.

Cartilage tissue has a very limited ability to regenerate. Symptomatic cartilage lesions are currently treated by various cartilage repair techniques. Multiple treatment techniques have been proposed in the last 30 years. Nevertheless, no single technique is accepted as a gold standard. Minced cartilage implantation is a newer technique that has garnered increasing attention. This procedure is attractive because it is autologous, can be performed in a single surgery, and is therefore given it is cost-effective. This narrative review provides an overview of the biological potential of current cartilage regenerative repair techniques with a focus on the translational evidence of minced cartilage implantation.

The Effects of Splitting an Above Elbow Cast: A biomechanical study.

BACKGROUND: Forearm fractures are one of the top three most common fractures in children. Treatment often includes immobilizing the arm in a cast extending above the elbow to help maintain fracture reduction and alignment. Complications from circumferential casting can occur including swelling in the forearm that can lead to neurovascular complications. About 16% of children require splitting of the cast to relieve the increased pressure. Our study investigates the impact the location of the split has on cast bending stiffness in an above elbow cast model. METHODS: A Sawbones© pediatric forearm model was used for application of a hybrid plaster-fiberglass cast to simulate treatment of a pediatric forearm fracture. The plaster was allowed to set for 20 minutes followed by application of a single fiberglass layer. The casts set for at least 24 hours and were then left intact or split along one of their 4 axes. Once categorized, the casts were subjected to biomechanical testing using an Instron ElectroPlus 10000 with a 3-point bending set up. The casts were tested until failure, and the load versus displacement curves were analyzed. Each category of casts was tested five times from both a volar and dorsal direction. RESULTS: When loaded dorsal to volar, intact casts were significantly stiffer than those split along the dorsal, radial, or volar surfaces (p=0.0062, 0.0267, 0.0024 respectively). There was no significant difference when comparing one axis of longitudinal split to another. Intact casts showed a significantly higher load to failure than those split along the radial border (p=0.0168). When loaded volar to dorsal, intact casts were significantly stiffer than those split along any axis. Intact casts showed a significantly higher maximum load to failure than those split along the radial or ulnar border (p=0.0247, 0.0112 respectively). CONCLUSION: Consideration should be given to splitting above elbow casts along the volar or dorsal surface, as those split along the radial or ulnar border tend to have lower maximum load to failure. CLINICAL RELEVANCE: To analyze the effect of splitting an above elbow cast on bending stiffness.