Scooter injuries: a new pediatric morbidity.

OBJECTIVE: To describe types of injuries, mechanisms of injury, and treatment of injuries caused by scooter use in children, and to discuss issues of injury prevention in children who use scooters. STUDY DESIGN: Data were collected from 14 children seen by a general pediatrician and an orthopedic surgeon over a 3-month period in the summer of 2000. Detailed histories were obtained from patients and their families, and medical records were reviewed. RESULTS: Eleven of the 14 patients suffered fractures. The injuries in the other 3 patients were a large abrasion, a laceration, and a septic knee. Half (7) of the children were injured within the first day of riding their scooter, and 13 of the 14 injuries occurred within the first month of scooter use. Only 5 patients used protective gear at the time of their injuries, and those patients were injured in unprotected parts of their bodies. CONCLUSIONS: The popularity of scooters presents a new cause of pediatric injuries and a significant health hazard to children. In our study, most injuries occurred shortly after children began scooter use, and younger children suffered the most severe injuries. Additional studies are needed to determine how scooter-related injuries can be prevented or minimized. scooters, injuries.

Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: a comparative study.

OBJECTIVES: To determine whether children with Type III displaced supracondylar fractures of the humerus that were pinned in a delayed fashion, defined as more than eight hours after fracture, had a greater need for open reduction than patients with similar fractures pinned more urgently, within eight hours after the trauma. Also, to determine whether those patients treated later fared any worse than patients treated earlier. DESIGN: Retrospective review of consecutive patients. SETTING: Level I pediatric trauma center at a tertiary children's hospital. PATIENTS: Fifty-eight consecutive patients, twenty-three with early pinning and thirty-five with delayed pinning. A subgroup of sixteen patients was followed for detailed clinical outcome. INTERVENTION: Closed or open reduction and percutaneous pinning MAIN OUTCOME MEASUREMENTS: Need for open reduction in either group. A separate subgroup was examined for carrying angle and evidence of low-grade compartment syndrome (such as grip strength and range of motion). RESULTS: There was no difference in the need for open reduction in the group that was delayed and pinned more than eight hours following fracture. Follow-up examination showed no clinical difference between the two groups in any parameter measured. CONCLUSIONS: These results indicate that many supracondylar fractures of the humerus can be treated safely in a delayed manner with an excellent clinical result and without unduly prolonging the hospital stay (such as with traction). This allows the patient to be NPO and the surgeon to operate in daylight hours, saving time, hospital resources, and fatigue.

Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges.

OBJECTIVES: To compare the hospital costs, charges, and reimbursement for treatment of pediatric femur fractures by two treatment methods: external fixation and 90-90 traction with spica casting. DESIGN: Retrospective clinical review. SETTING: Department of Orthopaedic Surgery, Children's Hospital Oakland, regional pediatric trauma center. PATIENTS: Twenty-nine consecutive patients between the ages of five and ten with a fracture of the femoral shaft were treated by one of two methods: external fixation (sixteen patients) or 90-90 skeletal traction followed by spica casting (thirteen patients). INTERVENTION: External fixation or 90-90 traction followed by spica casting. MAIN OUTCOME MEASURE: Hospital billing data including costs, charges, reimbursement for the initial inpatient hospitalization, and outpatient financial data until fracture union and cessation of treatment. RESULTS: There was no difference in age, total treatment time, mechanism of injury, or number of associated injuries between the two groups. The average charge for treatment with skeletal traction and spica casting was $32,094 per patient versus $21,439 for external fixation (p < 0.001). The average cost for treatment with traction and spica casting was $22,396 per patient versus $11,520 for external fixation (p < 0.001); reimbursement was $30,846 and $7,490, respectively (p < 0.001). The number of days in the hospital was larger for the traction group than for the external fixation group (22.3 days versus 4.7 days, p < 0.0001). CONCLUSIONS: External fixation of pediatric femoral shaft fractures results in decreased hospital costs and length of hospitalization, but produces significantly less income for the hospital when compared with skeletal traction followed by spica casting.

Overgrowth and outcome after femoral shaft fracture in children younger than 2 years.

Twenty-one children younger than 2 years with a fractured femur were evaluated retrospectively to determine limb overgrowth, efficacy, and outcome after treatment with immediate spica casting. All children had spica casts placed without general anesthesia within 24 hours of admission. Followup averaged 51 months (range, 24-110 months). Average shortening in the spica cast at initial application was 0.5 cm (range, 0-1.8 cm). The average length of hospitalization was 2.2 days. Three patients went home the same day, and seven were discharged after a single overnight stay in the hospital. No patients underwent closed manipulation or a cast change for malalignment of the fracture. Child abuse was identified as the mechanism of injury in eight of 12 (67%) children younger than 1 year of age and in only one of nine (11%) children between 1 and 2 years of age. Leg lengths were determined by measurement with tape and graduated blocks. At followup, the average limb length inequality was 0 cm, with an average net growth of 0.5 cm (range, -0.5-1.8 cm). Only one child had a limb length inequality of more than 1 cm as measured with tape (20 months of age), and no child had a limb length inequality of more than 1 cm as measured with blocks. No child or parent reported any residual pain, limp, or limitation of activity. The results of this study suggest that overgrowth does occur in children younger than 2 years. Additionally, immediate spica casting with early discharge to home is associated with few complications, no functional limitations, and minimal limb length inequality.

Evaluation and management of pediatric foot deformities.

There are myriad diagnoses that can occur in children's feet, and this article presents only a handful. Systematic evaluation beginning with a detailed history and careful physical examination, together with a knowledge of the natural history of these conditions, allows the primary care physician to be a much-needed resource for the family and provide cost-effective, efficient care while referring patients that need pediatric orthopedic intervention.

The role of selective dorsal rhizotomy in cerebral palsy: critical evaluation of a prospective clinical series.

This is a prospective observational study of a consecutive series of 34 children with spastic cerebral palsy treated at a single center. 10 had spastic quadriplegia and 24 had spastic diplegia. All were followed for at least one year. After selective dorsal rhizotomy (SDR), all children received one month of physical therapy at the center and were prescribed a program of physical therapy in their community. The children were assessed before and one year after SDR and physical therapy, using the Ashworth Scale, deep tendon reflex response, range of motion and the Gross Motor Function Measure. The results show that there is often a decrease in lower-extremity spasticity and functional improvement after SDR with physical therapy, but that there is considerable variability in outcome. Randomized prospective clinical trials with masked objective outcome measures are needed to determine the efficacy of SDR.

Hamstrings in cerebral palsy crouch gait.

After observing patients with increased anterior pelvic tilt following medial hamstring lengthening in cerebral palsy crouch gait, we became concerned that the hamstrings may be functionally important hip extensors. To evaluate this, we studied the three-dimensional motion of the hip and knee, calculated hamstring muscle length, and evaluated dynamic electromyography (EMG) of the medial hamstrings in 16 patients with diplegic cerebral palsy and crouch gait to determine if the hamstrings were extending the hip. Twelve of 16 patients exhibited marked prolongation of electrical activity in the medial hamstrings, and in eight of these 12, the hamstrings were contracting concentrically, thus aiding in hip extension during gait. Hamstrings may be important hip extensors in some cerebral palsy patients with crouch gait; however, other deformities contributing to crouch (such as hip flexion contracture) need to be considered before isolated hamstring lengthening is performed in these patients.

Magnetic resonance evaluation of "metaphyseal" changes in Legg-Calvé-Perthes disease.

Twenty involved hips in 16 patients with Legg-Calvé-Perthes disease (LCP) were studied with both plain radiographs and magnetic resonance imaging (MRI) scans to better evaluate the existence of "metaphyseal" changes. Thirty-four sets of radiographs and MRI scans were reviewed in a blinded fashion and compared for the presence and location of these changes. Of 23 hips with plain radiographic metaphyseal changes, 11 showed no such changes on MRI scans (48%). Twelve hips did show MRI changes located in the anterior metaphysis. One hip studied three times had a discrete cystic change located in the central metaphysis. Of 11 hips with no plain radiographic changes in the metaphysis, five showed metaphyseal changes on MRI. Metaphyseal changes in LCP remain poorly understood. Even with use of MRI, fine distinction between physis and metaphysis still proved difficult. It appears that most metaphyseal changes are physeal and epiphyseal irregularities. A few hips have truly metaphyseal lesions. The significance of these "cysts" is unclear.

"Metaphyseal" cysts in Legg-Calve-Perthes' disease.

Radiographic changes in the femoral metaphysis in Legg-Calve-Perthes' (LCP) remain poorly understood. Our hypothesis was that these "cysts" are not truly metaphyseal but are metaphyseal changes radiographically projected onto the metaphysis. Surface epiphyseal changes were made on a normal hip and a hip with LCP. These "lesions" appeared metaphyseal on radiograph, and in the specimen with LCP, projected deep within the metaphysis due to flattening and three-dimensional distortion. "Metaphyseal" cysts in LCP may be epiphyseal changes superimposed on the metaphysis. This would explain the correlation between the presence of a "metaphyseal" lucency and final result, since it is simply another indicator of the extent of epiphyseal involvement.

Primary ceramic hip replacement: a prospective study of 119 hips.

A prospective study of 119 consecutive primary ceramic total hip arthroplasties (Autophor, Smith & Nephew) was performed. Follow up was 100% at a minimum of 3 years. Six hips were revised during the course of the study (5%). Harris hip scores were 29.0 preoperatively, 78.7 at 6 weeks, and 92.6 at 3.4 years (range: 62 to 100). Ninety-one percent of the 107 surviving hips at follow up had a good or excellent hip score. The clinical results matched those of Mittelmeier. Thigh pain was a frequent finding, but rarely presented a clinical problem. Our incidence of thigh pain may be higher than that of others because no patients were lost to follow up. The ceramic portion of the Autophor Ceramic Hip was well tolerated clinically and radiographically. The femoral component was responsible for 2% to 4% of the revisions, and we have now replaced it with a stem designed for bony stabilization.