BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

Transphyseal Humeral Separations: An Often-Missed Fracture.

BACKGROUND: Transphyseal humeral separations (TPHS) are rare injuries often associated with non-accidental trauma, necessitating accurate diagnosis. This study aims to assess the accuracy of diagnosis of TPHS. METHODS: A retrospective review was conducted at five academic pediatric institutions to identify all surgically treated TPHS in patients up to 4 years of age over a 25-year period. Demographics, misdiagnosis rates, and reported misdiagnoses were noted. Comparative analyses were performed to analyze the effects of patient age and injury mechanism on misdiagnosis rates. RESULTS: Seventy-nine patients (average age: 17.4 months) were identified, with injury mechanisms including accidental trauma (n = 49), non-accidental trauma (n = 21), Cesarean-section (n = 6), and vaginal delivery (n = 3). Neither age nor injury mechanism were significantly associated with diagnostic accuracy in the emergency department (ED)/consulting physician group. ED/consulting physicians achieved an accurate diagnosis 46.7% of the time, while radiologists achieved an accurate diagnosis 26.7% of the time. Diagnostic accuracy did not correlate with Child Protective Services (CPS) involvement or with a delay in surgery of more than 24 h. However, a significant correlation (p = 0.03) was observed between injury mechanism and misdiagnosis rates. CONCLUSION: This multicenter analysis is the largest study assessing TPHS misdiagnosis rates, highlighting the need for raising awareness and considering advanced imaging or orthopedic consultation for accurate diagnosis. This also reminds orthopedic surgeons to always have vigilant assessment in treating pediatric elbow injuries. LEVEL OF EVIDENCE: Level III-Retrospective Cohort Study.

Spontaneous improvement of olisthetic scoliosis in children following lumbosacral fusion for high-grade spondylolisthesis: A report of four new cases and systematic review of the literature.

Background: The study aim was to present four new well-documented cases of spontaneous improvement of olisthetic scoliosis and to analyze well-documented cases from the literature. Methods: Surgical log search and systematic review were conducted. Inclusion criteria were (1) age less than 18 years, (2) symptomatic high-grade (≥50%) spondylolisthesis, (3) scoliosis ≥20o, (4) primary surgical treatment via lumbosacral fusion, (5) complete x-rays, and (6) minimum 1-year radiographic follow-up or until curve resolution. Results: A total of 13 patients with average age of 13.9 years were included in the study, 4 from the authors' surgical logs and 9 from the literature. Slip percentage of L5-S1 ranged from 51% to 95%. Olisthetic curve magnitude averaged 34.6° (range: 20°-45°) with majority (8/13) demonstrating long thoracic curves with lateral trunk shift. All but one of these were apex right with rightward trunk shift. The remainder of the curves were isolated lumbar curves, with an apex left morphology without trunk shift. Eleven of the 13 patients showed curve improvement following isolated lumbosacral fusion. Three patients experienced a decrease in curve magnitude of 12°-28° and eight patients enjoyed complete resolution (≤10°) of their scoliosis. Conclusion: The current study summarizes 13 well-documented cases of olisthetic scoliosis (4 new cases and 9 from the literature) that associated with symptomatic high-grade spondylolisthesis. All were treated via a primary posterior lumbosacral fusion strategy. Eleven of the 13 curves showed spontaneous improvement (8 complete resolution of scoliosis) following their lumbosacral surgery. Level of evidence: Therapeutic level IV.

Pediatric Lateral Humeral Condyle Fractures: Reliability of a Modified Jakob Classification System and its Impact on Treatment Planning With or Without Arthrography.

BACKGROUND: Various lateral humeral condyle fracture (LHCF) classification systems have been in use since the 1950s, but limited research exists on their reliability. The most widely utilized, yet un-validated system is that of Jakob and colleagues. The purpose of the current study was to analyze the reliability of a modified Jakob classification system and its value in guiding treatment either with or without arthrography. METHODS: Interrater and intrarater reliability studies were performed using radiographs and arthrograms from 32 LHCFs. Radiographs were presented to 3 pediatric orthopaedic surgeons and 6 pediatric orthopaedic surgery residents who were asked to classify the fractures according to a modified Jakob classification system, enunciate their treatment plan, and whether they would utilize arthrography. Classification was repeated within 2 weeks to assess intrarater reliability. The treatment plan using radiographs only and radiographs with arthrography were compared at both rating points. RESULTS: The modified Jakob system had excellent interrater reliability using only radiographs with a kappa value of 0.82 and an overall agreement of 86%. The average kappa for intrarater reliability using only radiographs was 0.88 with a range of 0.79 to 1.00 and an average overall agreement of 91% with a range of 84% to 100%. Interrater and intrarater reliability was poorer using both radiographs and arthrography. On average, arthrography changed the treatment plan in 8% of cases. CONCLUSIONS: The modified Jakob classification system proved to be a reliable classification system for LHCFs, independent of arthrography, given the excellent free-marginal multirater kappa values. LEVEL OF EVIDENCE: Level III-diagnostic.

Clavicular Fractures in the Adolescent.

➤: Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively. ➤: Although rare, in certain patients or fracture patterns, nonoperative management may be associated with delayed healing, prolonged disability, and/or poor functional outcome requiring secondary reconstruction. ➤: When warranted, primary open reduction and internal fixation with plate and screw application has consistently good outcomes with a low complication rate, with the most common complication being implant-related symptoms requiring a secondary surgical procedure for implant removal. ➤: Prospective, comparative studies examining operative and nonoperative treatment, including measures of early return to function, injury burden, return to athletic activity, complication and reoperation rates, and shoulder-girdle-specific, long-term outcome measures are warranted to further elucidate which fractures may benefit from primary fixation.

Comparative Effectiveness of Nonoperative Versus Operative Treatment of Completely Displaced Clavicle Shaft Fractures Among Children.

The goal of this study was to compare outcomes among children treated nonoperatively vs operatively for completely displaced clavicle fractures. This was a retrospective cohort study of nonoperative vs operative treatment of completely displaced clavicle fractures sustained between 2006 and 2015 among pediatric patients. Data were collected on patient demographics, fracture characteristics, time to return to full activities, treatment complications, and patient-reported outcome measures. Fifty-five patients were identified in the nonoperative group, with a mean age of 11.6 years (range, 8-14 years). The operative group contained 55 patients, with a mean age of 14.3 years (range, 9-17 years). All fractures healed, with a mean time to return to full activities of 90.4 days in the nonoperative group and 89.7 days in the operative group (P=.941). Twelve (22%) nonoperative patients sustained a refracture of their clavicle compared with 4 patients in the operative group (P=.031). Fifteen patients (27%) in the operative group required a second surgery for removal of surgical implants. On the shortened form of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, 17 of the 22 nonoperative patients reported a score of zero (indicating no disability) (range, 0-7) vs 22 of 25 in the operative group (range, 0-9) (P=.329). Patients treated nonoperatively had a 22% rate of refracture, whereas patients treated operatively had a 27% rate of undergoing a second surgery for removal of surgical implants. These data can aid in the shared decision-making process with patients and families when deciding on treatment for displaced pediatric clavicle fractures. [Orthopedics. 2022;45(6):373-377.].

Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age.

BACKGROUND: The transphyseal distal humeral fracture has been well described as a concerning fracture pattern for non-accidental trauma (NAT) in young pediatric patients. Because of the infrequent presentation of this fracture, the association historically has been anecdotal. The purpose of this study was to determine and compare the incidence of NAT among displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in children <3 years of age. METHODS: All displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in patients <3 years of age admitted because of injury during an 18-year period were reviewed retrospectively for inclusion. Patient demographics, mechanisms of injury, results of child protective services investigations, and medical records were reviewed. A chi-square test was utilized to analyze significance for categorical data; p values of <0.05 were defined as significant. RESULTS: The charts of 23 transphyseal distal humeral and 205 supracondylar humeral fracture cases were reviewed. NAT was the cause for 6 (26%) of the displaced transphyseal distal humeral fractures and 4 (2%) of the displaced supracondylar fractures. The associated risk of NAT was 13 times greater (95% confidence interval [CI], 4.05 to 43.7; p < 0.001) for children admitted for operative management of displaced transphyseal distal humeral fractures compared with those admitted for operative management of displaced supracondylar humeral fractures. CONCLUSIONS: The classic 1980 paper by DeLee et al. sensitized the orthopaedic community to the relationship between transphyseal distal humeral fractures and child abuse. Our study is the first, to our knowledge, to bring statistical weight to this association. We found a 13-times-greater risk of NAT for children <3 years of age who sustain a displaced transphyseal distal humeral fracture compared with a displaced supracondylar fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonunion of the Clavicle Among Children: A Review of the Literature and a Report of Three New Cases.

Nonunion of the clavicle among children and adolescents is rare. A systematic review was conducted to identify published reports of nonunion of the clavicle among children after conservative treatment. A retrospective study was performed of 2096 children who were treated for clavicle fractures at our institution to identify cases of nonunion. Fourteen studies (27 children) from the literature met the inclusion criteria, and 3 new cases from our institution were identified. The mean age at injury was 11 years. Male sex, age younger than 12 years at the time of injury, and refracture of the clavicle are possible predisposing factors for nonunion. [Orthopedics. 2022;45(4):e190-e195.].

Unicolumnar Pin Fixation of Type III Supracondylar Humeral Fractures Is Associated With Over 3 Times Higher Odds of Lost Reduction.

OBJECTIVES: To compare the rate of lost reduction between 2 groups of non-age-segregated type III supracondylar humeral fracture patients: a unicolumnar versus bicolumnar fixation group. DESIGN: Retrospective cohort study. SETTING: Pediatric Academic Trauma Center. PATIENTS: We identified 257 patients with type III supracondylar humerus fractures from surgical billing records over a 5-year period. There were 183 patients identified with bicolumnar fixation (71.2%) and 74 patients identified with unicolumnar fixation (28.8%). INTERVENTION: Closed reduction percutaneous pinning of the distal humerus. MAIN OUTCOME MEASURES: The primary outcome measure was difference in rate of lost reduction between patients with bicolumnar (lateral and medial column) and unicolumnar (lateral column only) fixation (Fig. 1). The reduction and fixation at the time of fluoroscopy was assessed using the Baumann angle, Gordon index, and anterior humeral line. Loss of reduction was assessed at time of healing, defined by a Baumann angle change ≥10 degrees and Gordon index of ≥50% (Fig. 2). RESULTS: There were 183 patients with bicolumnar fixation and 74 patients with unicolumnar fixation included in the study (average age 5.8 years; range, 2-14 years). The rate of lost reduction in patients with bicolumnar fixation was 6.01% (11/183), whereas 17.57% (13/74) of patients with unicolumnar fixation experienced lost reduction. These rates were significantly different (P = 0.008) with a 3.3 times higher odds (95% confidence interval = 1.3-8.6) of lost reduction with unicolumnar fixation. CONCLUSIONS: There is a statistically significant increase in the rate of supracondylar fracture loss of reduction for patients with unicolumnar fixation when compared with bicolumnar fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transphyseal Humeral Separations: What Can We Learn? A Retrospective, Multicenter Review of Surgically Treated Patients Over a 25-Year Period.

PURPOSE: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. This multicenter study aimed to assess the various patient characteristics, injury patterns, treatments, outcomes, and complications in a large series of these injuries. METHODS: A retrospective review was conducted at 5 pediatric institutions to identify TPHS that were treated surgically in patients 0 to 3 years of age over a 25-year period. Patient demographics, mechanisms of injury, Child Protective Services involvement, diagnostic modalities, time to surgery, pin size and configuration, time to fracture union, and complications were recorded. RESULTS: A total of 79 patients aged 0 to 46 months, with a mean of 17.6 months, were identified and followed for a median of 57 days postoperatively. The most common mechanism of injury was accidental trauma (n=49), followed by nonaccidental trauma (n=21), cesarean section (n=6), and vaginal delivery (n=3). Child Protective Services were involved in 30 cases (38%). Additional injuries were reported in 19 of the patients; most commonly additional fractures including the humerus, rib, and skull fractures. All patients had elbow radiographs, whereas 4 patients had an elbow ultrasound and/or a magnetic resonance imaging. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intraoperatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), averaging utilization of 2.2 pins, and 2 patients underwent an open reduction. In total, 11 complications (14%) were noted, including decreased range of motion (n=4), cubitus varus/valgus (n=6), and need for additional surgery (n=1). No cases of avascular necrosis or physeal arrest were found. No losses of reduction were noted. CONCLUSIONS: This multicenter review provides the largest known demographic and outcomes data on TPHS. TPHS have excellent outcomes in the vast majority of patients when treated surgically. Nonaccidental trauma accounted for 27% of these injuries so it needs to remain high on the differential diagnosis. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST): Development and Validation of a Prognostic Model in Untreated Adolescent Idiopathic Scoliosis Using the Simplified Skeletal Maturity System.

STUDY DESIGN: Prognostic study and validation using prospective clinical trial data. OBJECTIVE: To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. METHODS: The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). RESULTS: The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89-0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71-0.72 and NPVs of 0.85-0.93. CONCLUSIONS: This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. LEVEL OF EVIDENCE: Level 1, prognostic.

Pediatric Proximal Radial Shaft Fractures Treated Nonoperatively Fail to Maintain Acceptable Reduction up to 70% of the Time.

OBJECTIVE: To compare early radiographic malalignment rates of conservatively treated proximal radial shaft fractures to more distal fractures. DESIGN: Retrospective cohort study. SETTING: A pediatric, Level 1 trauma center. PATIENTS/PARTICIPANTS: We identified a group of 401 pediatric patients who were treated for a complete radial shaft fracture at our institution. Of this group, 309 patients met our inclusion criteria for attempted nonoperative management and were evaluated in our study. INTERVENTION: Closed reduction and casting. MAIN OUTCOME MEASUREMENT: The primary outcome of the study was the failure rate of nonoperative management as defined by residual angulation of the radius assessed on follow-up radiographs. RESULTS: Proximal third fractures were significantly more likely to fail conservative treatment (P < 0.0001) as they exceeded angulation criteria 70% (32/46) of the time compared with more distal fractures (33%; 87/263). In terms of halves (P = 0.0003), the proximal half fractures failed 50% (55/111) of the time while 29% (57/198) of distal half fractures failed conservative treatment. Failure of closed reduction and casting was 4.6 times higher (95% confidence interval, 2.3-9.1) in proximal third fractures and 2.4 times greater (95% confidence interval, 1.5-3.9) in proximal half fractures compared with their more distal counterparts. CONCLUSIONS: Given the impressive rate of failure of closed reduction and casting of proximal third radial shaft fractures, the treating orthopaedic surgeon should prudently consider all management options. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Midshaft Clavicle Fracture Pearls and Pitfalls.

Pediatric diaphyseal clavicle fractures are a common injury, particularly in the adolescent athlete. There are no consensus guidelines for operative versus nonoperative management of these injuries; however, there has been a dramatic increase in operative treatment over the past 15 years, primarily guided by literature pertaining to the adult population. Despite this trend, current literature suggests that the majority of these injuries can be treated nonoperatively with good functional outcomes, high rates of return to sport, and low incidence of complications such as nonunion, symptomatic malunion, and refracture. For the rare patient treated nonoperatively who develops a symptomatic nonunion or malunion, delayed corrective surgery remains a viable treatment option. When surgical fixation is pursued, good outcomes have been universally reported, but the optimal indication for surgery remains elusive in this adolescent population.