Volar Distal Radius Buckle Fractures: Is Bracing and Home Management Safe?

BACKGROUND: A removable brace with home management is widely accepted treatment for distal radius buckle fractures, which most commonly involve the dorsal cortex. PURPOSE: The purpose of this study is to determine if a removable brace and home management treatment is safe for volar distal radius buckle fractures. MATERIALS AND METHODS: Isolated distal radius buckle fractures in children (3-16 years) diagnosed at an acute care visit (April 1, 2019 to May 31, 2022) were identified. Final diagnosis was confirmed using strict criteria including cortical buckling without cortical breach or physeal involvement. Cortical buckling was categorized as either dorsal or volar. Demographic data, mechanism of injury, treatment, and any complications were recorded and analyzed. RESULTS: Three hundred thirty-three fractures were either dorsal (254, 76%) or volar (79, 24%) buckle fractures. Mean age (SD) for volar fractures (9.3 [2.2 years]; range, 4-14 years) was significantly higher than for dorsal fractures (8.5 (3.0 years); range, 3-15 years; P = 0.012). More girls had volar fractures (48 [60%], P = 0.006). Most fractures occurred after a standing-height fall. Two hundred forty-four (96%) dorsal and 76 (96%) volar fractures were initially treated with a removable brace. Two hundred fourteen (84%) dorsal and 66 (84%) volar fractures had orthopedic follow-up. Brace treatment continued for 167 (167/204, 82%) dorsal and 56 (56/63, 89%) volar fractures. Treatment changed from initial brace to cast for 37 (37/204, 18%) dorsal fractures and 7 (7/63, 11%) volar fractures, influenced by caregiver preference and/or sport participation requirements. Only 1 (1/79, 1%) patient with a volar fracture returned for an additional visit for persistent pain. CONCLUSIONS: When diagnosis of volar buckle fracture is made using the same strict criteria used for dorsal buckle fractures, removable brace and home management treatment is safe. Shared decision making with caregivers may alter buckle fracture treatment.

Reducing Rigid Immobilization for Toddler's Fractures: A Quality Improvement Initiative.

Background: Toddler's fractures are one of the most common orthopedic injuries in young walking-age children. They are defined as nondisplaced spiral-type metaphyseal fractures involving only the tibia without any injury to the fibula and are inherently stable. We aimed to use quality improvement methodology to increase the proportion of patients with toddler's fractures treated without cast immobilization at a large tertiary referral pediatric orthopedic center from a baseline of 45.6%-75%. Methods: Baseline data on patient volume and treatment regimens for toddler's fractures were collected starting in February 2019. Monthly data were collected from the electronic medical record and reviewed to determine treatment (cast versus noncast immobilization) and tracked using statistical process control charts (p-chart). After determining the root causes of treatment using immobilization, interventions tested and adopted included physician alignment of expectations for treatment, sharing unblinded compliance data with providers, updating patient education materials, and updating resident education and reference materials. Results: After interventions were in place, the percentage of patients treated without CAST immobilization increased from 45.6% to 90% (P ≤ 0.001). We also observed improvement in our process measure to increase the percentage of this population receiving boot immobilization during new patient visits in our orthopedic clinics (4.15% to 52%, P ≤ 0.001). Conclusions: By aligning provider and family expectations for treatment, demonstrating no clinical need for cast immobilization, and bringing awareness of compliance to appropriate guidelines, our institution was able to improve care for patients with toddler's fractures and reduce financial and care burdens for families.

How Much Bullying and Discrimination Are Reported by Sexual and Gender Minorities in Orthopaedics?

BACKGROUND: Discriminatory practices against minority populations are prominent, especially in the workplace. In particular, lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals experience several barriers and stressors more often than individuals who do not identify as LGBTQ+. Mistreatment is common among these individuals in their personal and professional lives. However, representation and perceptions of discrimination and bullying among attendings, residents, medical students, and other professionals who identify as LGBTQ+ and are "out" (openly acknowledging and expressing one's sexual orientation or gender identity) is seldom studied in orthopaedic surgery. QUESTIONS/PURPOSES: (1) How often are orthopaedic trainees and professionals who identify as LGBTQ+ out in their workplaces? (2) What proportion of these individuals report experiencing discrimination, bullying, or differential treatment? (3) Is there regional variation in these reported experiences of bullying and discriminatory behaviors by orthopaedic trainees and professionals in the LGBTQ+ community? METHODS: Individuals registering for Pride Ortho, a community of LGBTQ+ individuals and their allies established in 2021 to provide mentorship, networking, and a sense of community among its members, completed an internet-based survey developed by organization leadership. A total of 156 individuals registering for the Pride Ortho community were eligible to participate in the internet-based survey. In all, 92% (144 of 156) fully completed the survey, 6% (10 of 156) partially completed it, and 1% (2 of 156) did not complete any part of the survey. Most respondents (64% [100 of 156]) identified as being LGBTQ+, with 77 members at the attending level of their careers. More than half of LGBTQ+ members (56% [56 of 100]) identified as cisgender women (individuals who identify as women and who were born female). Demographic information was privately collected and deidentified, and included sex assigned at birth, gender expression or identity (the social constructed role that an individual chooses to inhabit, regardless of that individual's assigned sex at birth), sexual orientation, self-identified race, location, level of training, and orthopaedic subspecialty. RESULTS: Ninety-four percent (94 of 100) of LGBTQ+ respondents reported being out at their workplace, with nearly one-third of respondents indicating they were only partially out. Most (74% [74 of 100]) respondents reported either "yes" or "maybe" to perceived experiences of bullying, discrimination, or being treated differently. All individuals who partially completed the survey were straight or heterosexual and did not answer or answered "not applicable" to being out in their workplace. These individuals also all answered "no" to experiencing bullying, discrimination, or being treated differently. There was no geographic variation in reported experiences of bullying and discriminatory behaviors by orthopaedic trainees and professionals. CONCLUSION: Most LGBTQ+ orthopaedic trainees and professionals are out in their workplaces, although they report experiencing discrimination and bullying more than do non-LGBTQ+ individuals. Bullying and discrimination can deter individuals from beginning and completing their training in orthopaedic surgery. We recommend that orthopaedic institutions not only enforce existing antidiscrimination legal mandates but also increase the visibility of LGBTQ+ faculty and residents. This effort should include the implementation of diversity and sensitivity training programs, strengthened by a structured process of monitoring, reporting, and integrating feedback from all members in the workplace to continuously refine policy adherence and identify the root cause of the reported perceptions of bullying and discrimination. CLINICAL RELEVANCE: To deepen our understanding of the experiences faced by sexual and gender minorities in orthopaedic surgery settings, it is crucial to quantify reports of perceived bullying and discrimination. Addressing these issues is key to creating a more diverse and empathetic workforce within orthopaedic institutions, which in turn can lead to improved patient care and a better work environment. Recognizing and understanding the specific contexts of these experiences is an essential starting point for developing a truly inclusive environment for both trainees and attending physicians.

LGBTQ+ Perspective in Hand Surgery: Surgeon and Patient.

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals and patients face high levels of discrimination both in the workplace and in the clinic setting, with more than 25% of LGBTQ+ people experiencing discrimination in the workplace due to their sexual orientation. Hand Surgery stands to continue to advance by encouraging the brightest students into the field no matter their background. LGBTQ+ patients also have specific needs within the field of Hand Surgery, where we are uniquely positioned to treat them or guide them by being well versed in the needs of the community.

To Err is human, but what happens when surgeons Err?

BACKGROUND: Physicians involved in adverse events may suffer from second victim syndrome and can experience emotional and physical distress long after the complication occurred. We sought determine the prevalence of second victim syndrome among surgeons at our children's hospital and evaluate any differences in how surgeons respond to adverse events based on their age, position, and gender. METHODS: An anonymous 19-question questionnaire distributed via institutional emails linking to an anonymous Research Electronic Data Capture (REDCap) survey. Eligible participants included all surgeons and rotating surgical trainees at our hospital. RESULTS: Of 64 faculty surgeons eligible to participate, 63 surveys were returned for a 98% completion rate. Ten additional surveys from surgical trainees were completed for a total of 73 participants. Eighty-four percent reported having had difficulty dealing with a poor outcome or unhappy patient/family. Speaking with a colleague was the most common coping strategy, reported by 82%. Fifty-six percent indicated they believed reporting a poor outcome would have negative ramifications for them. Younger surgeons were more likely to suppress their feelings following an adverse event, and trainees were less likely to advise their peers to speak to a superior about the event (p < 0.05). CONCLUSION: There is a high prevalence of second victim syndrome among surgeons at our children's hospital. There exist differences in ways that surgeons respond to adverse events based on age and position. Healthcare institutions should establish formal mechanisms of support to shift the culture towards one where help is actively sought and offered. LEVEL OF EVIDENCE: IV.

Coaching, Separate from Mentoring, May Provide Skill Acquisition, Improved Well-Being, and Career Advancement in Orthopaedic Surgery: AOA Critical Issues.

ABSTRACT: Coaching is separate from mentoring, and can include life coaching, skills coaching, and behavior coaching. Life coaching can focus on purpose, work-life balance, well-being, and career path. Skills coaching encourages mastery and promotes autonomy. Behavior coaching may be mandated for a disruptive surgeon. Coaching has been shown to reduce burnout and promote well-being and can potentially advance a surgeon's career trajectory and leadership skills.

LGBTQ+ in Orthopaedics: Creating an Open and Inclusive Environment.

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals may encounter added challenges in the healthcare setting. Both providers and patients may face discrimination based on their sexual orientation or gender identity, which may lead to avoidance or delay in seeking care. LGBTQ+ physicians often choose not to disclose their sexual orientation because of concerns about harassment, isolation, and depression. Orthopaedic surgery remains the least diverse medical specialty and there is inconsistent training about the needs and cultural issues that affect sexual and gender minority individuals. Furthermore, orthopaedic research specific to LGBTQ+ patients and physicians is exceedingly limited. By encouraging mentorship and improving awareness of the challenges that this community faces, the field of orthopaedic surgery can work to foster an open and inclusive environment that is conducive to the experience of all patients, trainees, and healthcare personnel.

Brachial Plexus Birth Injuries.

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

From Self-efficacy to Imposter Syndrome: The Intrapersonal Traits of Surgeons.

BACKGROUND: Demographic differences among surgical trainees regarding intrapersonal traits, such as imposter syndrome and assertiveness, have become widely acknowledged. However, many of these characteristics have not been examined in tandem, nor among both trainees and surgeons in practice. This study aimed to address these knowledge gaps. METHODS: This was an anonymous, voluntary survey study comprised of validated measures of (1) self-efficacy, (2) imposter syndrome, (3) assertiveness, (4) perfectionism, and (5) self-rated likeability. A multimodal recruitment strategy was used and surgeons across all subspecialties were eligible for inclusion. RESULTS: A total of 296 participants were included, with 54% identifying as female (n = 161) and 72% between the ages of 25 and 40 years of age (n = 212). Imposter syndrome, assertiveness, and perfectionism scales were normally distributed; self-efficacy and self-rated likeability scales demonstrated slight negative skew. Self-identified male sex was associated with less imposter syndrome (P < 0.001) and perfectionism (P = 0.035) and higher assertiveness (P < 0.001). Imposter syndrome was less common among older age groups (P = 0.001). CONCLUSIONS: Surgeons are a self-efficacious group of perfectionists with widespread variability in imposter syndrome and assertiveness. Female sex and younger age were associated with more imposter syndrome and less assertiveness, highlighting an opportunity for early career coaching.

Knowledge, Attitudes, and Practices in the Orthopaedic Care of Sexual and Gender Minority Youth: A Survey of Two Pediatric Academic Hospitals.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) children and adolescents continue to experience unmet healthcare needs, partly because of clinician biases, discrimination, and inadequate education. Although clinician attitudes and knowledge related to sexual and gender minority health have been well studied in other medical specialties, these have been scarcely studied in orthopaedics. QUESTIONS/PURPOSES: (1) What are pediatric orthopaedic healthcare professionals' attitudes (perceived importance, openness, comfort, and confidence) toward caring for sexual and gender minority youth? (2) What do pediatric orthopaedic healthcare professionals know about caring for this patient population? (3) What factors are associated with clinician attitude and/or knowledge? (4) What existing initiatives to improve orthopaedic care for this population are clinicians aware of at their home institutions? METHODS: All 123 orthopaedic healthcare professionals at two pediatric academic hospitals in the Midwestern and Northeastern United States were sent a 34-question, internet-based, anonymous survey. The survey queried respondent demographics, attitudes, knowledge, and practice behaviors at their home institutions related to the care of sexual and gender minority youth. Respondent attitudes were queried using the Attitudes Summary Measure, which is a survey instrument that was previously validated to assess clinicians' attitudes regarding sexual and gender minority patients. Items used to assess knowledge and practice behaviors were developed by content experts in LGBTQ health and/or survey design, as well as orthopaedic surgeons to improve face validity and to mitigate push-polling. Attitude and knowledge items used a 5-point Likert scale. Sixty-six percent (81 of 123) of clinicians completed the survey. Of those, 47% (38 of 81) were physicians, 73% (59 of 81) were licensed for fewer than 20 years, 63% (51 of 81) were women, and 53% (43 of 81) described themselves as liberal-leaning. The response proportions were 73% (38 of 52) among eligible physicians specifically and 61% (43 of 71) among other clinicians (nurse practitioners, physician assistants, and registered nurses). To assess potential nonresponse bias, we compared early responders (within 2 weeks) with late responders (after 2 weeks) and found no differences in responder demographics or in questionnaire responses (all p > 0.05). The main outcome measures included responses to the attitude and knowledge questionnaire, as well as the existing practices questionnaire. To answer our research questions regarding clinician attitudes knowledge and awareness of institutional initiatives, we compared participant responses using chi-square tests, the Student t-test, and the McNemar tests, as appropriate. To answer our research question on factors associated with questionnaire responses, we reported data for each question, stratified by hospital, years since licensure, and political leaning. Comparisons were conducted across strata using chi-square tests for Likert response items and ANOVA for continuous response items. All p values less than 0.05 were considered significant. RESULTS: Of the respondents who reported feeling comfortable treating lesbian, gay, and bisexual (sexual minority) youth, a small proportion reported feeling confident in their knowledge about these patients' health needs (99% [80 of 81] versus 63% [51 of 80], 36% reduction [95% confidence interval 23% to 47%]; p < 0.001). Similarly, of those who reported feeling comfortable treating transgender (gender minority) youth, a smaller proportion reported feeling confident in their knowledge of their health needs (94% [76 of 81] versus 49% [37 of 76], 45% reduction [95% CI 31% to 59%]; p < 0.001). There was substantial interest in receiving more education regarding the health concerns of LGBTQ people (81% [66 of 81]) and being listed as an LGBTQ-friendly clinician (90% [73 of 81]). Factors that were associated with select attitude and knowledge items were duration of licensure and political leaning; gender identity, institutional affiliation, educational degree, or having LGBTQ friends and family were not associated. Many respondents were aware of the use of clinic intake forms and the electronic medical record to collect and provide patient gender identity and sexual orientation data at their practice, as well as signage and symbols (for example, rainbow posters) to cultivate LGBTQ-welcoming clinic spaces. CONCLUSION: There were varying degrees of confidence and knowledge regarding the health needs of sexual and gender minority youth among pediatric orthopaedic healthcare professionals. There was considerable interest in more focused training and better use of medical technologies to improve care for this population. CLINICAL RELEVANCE: The study findings support the further investment in clinician training opportunities by healthcare administrators and orthopaedic associations related to the care of sexual and gender minority patients, as well as in the expansion of medical documentation to record and report important patient information such as pronouns and gender identity. Simultaneously, based on these findings, clinicians should engage with the increasing number of educational opportunities, explore their personal biases, and implement changes into their own practices, with the ultimate goal of providing equitable and informed orthopaedic care.

Ruth Jackson Orthopaedic Society: Promoting Women in Orthopaedics.

The Ruth Jackson Orthopaedic Society is the oldest organization in the world, supporting women in orthopaedic surgery. The mission is to promote the professional development of women in orthopaedics throughout all stages of their careers. Essential components of the strategic plan include collaboration, communication, and education, with specific domains including diversity and inclusion, professional development, membership, research, and organizational excellence. As of 2021, there are 1,161 members, with a large focus on mentorship and scholarship, providing multiple opportunities for members to excel in orthopaedics. At the core of the Ruth Jackson Orthopaedic Society is the commitment to one another, embracing the uniqueness of being a woman in orthopaedic surgery.

Long-read whole genome sequencing reveals HOXD13 alterations in synpolydactyly.

Synpolydactyly 1, also called syndactyly type II (SDTY2), is a genetic limb malformation characterized by polydactyly with syndactyly involving the webbing of the third and fourth fingers, and the fourth and fifth toes. It is caused by heterozygous alterations in HOXD13 with incomplete penetrance and phenotypic variability. In our study, a five-generation family with an SPD phenotype was enrolled in our Rare Disease Genomics Protocol. A comprehensive examination of three generations using Illumina short-read whole-genome sequencing (WGS) did not identify any causative variants. Subsequent WGS using Pacific Biosciences (PacBio) long-read HiFi Circular Consensus Sequencing (CCS) revealed a heterozygous 27-bp duplication in the polyalanine tract of HOXD13. Sanger sequencing of all available family members confirmed that the variant segregates with affected individuals. Reanalysis of an unrelated family with a similar SPD phenotype uncovered a 21-bp (7-alanine) duplication in the same region of HOXD13. Although ExpansionHunter identified these events in most individuals in a retrospective analysis, low sequence coverage due to high GC content in the HOXD13 polyalanine tract makes detection of these events challenging. Our findings highlight the value of long-read WGS in elucidating the molecular etiology of congenital limb malformation disorders.

A 15-Year Report on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States.

This study was undertaken to update reports from 2004 to 2005 through 2008 to 2009, and 2009 to 2010 through 2013 to 2014, including 5 additional years of GME Track data. Our hypothesis is there have been no significant changes during the past 5 years in the distribution of Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics residency programs that train female residents, compared with the previous 10 years. METHODS: Data for ACGME-accredited orthopaedics residency training programs in the United States were analyzed for 5 consecutive academic years (2014-2015 through 2018-2019). Programs were classified as having no women, 1 woman, 2 women, or greater than 2 women in training. Programs were analyzed for percentage of female residents and classified as having above the national average (>20%), similar to the national average (between 10 and 20%), or below the national average (<10%). RESULTS: Analysis of the original 5 years (2004-2009) compared with the most recent data (2014-2019) demonstrated a statistically significant improvement in the number of programs training women (p < 0.001). From 2004 to 2009 to 2014 to 2019, the absolute number and percent of female trainees have increased (p < 0.001). Similar analysis of the middle 5 years (2009-2014) compared with the most recent 5 years (2014-2019) did not demonstrate a statistically significant change (p = 0.12). From 2014 to 2019, residency programs in the United States continue to train women at unequal rates: 37 programs had no female trainees, while 53 programs had >20% female trainees during at least one of these 5 years. CONCLUSIONS: Female medical students continue to pursue orthopaedics at rates lagging behind all other surgical specialties. Not all residency programs train women at equal rates. If the rate of training of female residents over the past 15 years were projected over time, we would not achieve 30% women within orthopaedics residency training programs until approximately 2060. LEVEL OF EVIDENCE: III.

Distal Radius Physeal Bar and Ulnar Overgrowth: Indications for Treatment.

BACKGROUND: Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop. METHODS: A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded. RESULTS: Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis. CONCLUSIONS: Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.

Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement.

BACKGROUND: Each year, our institution performs more than 34,000 surgical cases and obtains close to 10,000 surgical specimens. Within those procedures, we averaged 10 errors for every 1,000 surgical specimens. Any level of preventable harm is unacceptable, as it could lead to risks of treatment delay, improper therapy selection, or missed diagnoses. This quality improvement (QI) effort aimed to decrease errors in surgical specimens from 10 errors per 1,000 surgical specimens to 0 errors each month. METHODS: Using the Institute for Healthcare Improvement Model for Improvement QI methodology, we determined the root causes of error, identified key drivers, and tested change interventions. We implemented changes in surgical specimen labeling, standardized specimen time-out and reconciliation processes, and optimized a method of communication between consultants, surgeons, operating room staff, and laboratory staff with the implementation of a Specimen Request Form. RESULTS: Over 46 months, we identified 234 specimen errors in 33,962 surgical pathology specimens. The error rate was reduced from 10 to 2.31 errors per 1,000 specimens. The mean rate of order errors decreased from 3.66 to 0.13 per month, and the mean rate of labeling-related errors decreased from 1.5 to 0.5 per month. CONCLUSIONS: A multidisciplinary project team implemented changes to specimen test requesting and intraoperative specimen handling with an associated reduction in errors to reduce potential patient harm involving surgical specimen errors. This article demonstrates how applying these methods and interventions can be associated with a reduction in surgical specimen errors.

Congenital Radioulnar Synostosis.

Congenital radioulnar synostosis is a rare condition resulting in fusion of the proximal portions of the radius and ulna. Patients commonly present in early childhood with functional deficits because of limited forearm rotation and fixed positioning of the forearm. Compensatory motion and hypermobility are frequently observed at the wrist and shoulder, which may predispose these joints to overuse injury. Plain radiographs are used for diagnosis and classification. The most commonly used classification does not aid in treatment decisions. Limited high-level evidence exists to guide management because the literature primarily consists of case reports and case series. Nonsurgical management is often used, yet surgical management is most commonly reported in the literature. Resection of the synostosis has been shown to have high-complication rates and lead to subpar outcomes. Currently, surgical management most commonly involves one or more derotational osteotomies.

How Does Representation of Women on Editorial Boards Compare Among Orthopaedic, General Surgery, and Internal Medicine Journals?

BACKGROUND: Women have historically been underrepresented as editors of peer-reviewed medical journals. Studies have demonstrated that there are differences in editorial board reviewer behavior based on gender, suggesting that greater representation by women on editorial boards may improve the quality and diversity of the review process. Therefore, the current representation of women on the editorial boards of orthopaedic journals, particularly compared with peer-reviewed surgical and medical journals, is of interest. QUESTIONS/PURPOSES: (1) What is the representation of women as members of editorial boards of prominent orthopaedic surgery journals? (2) How does it compare with representation on the editorial boards of journals in general surgery and internal medicine? METHODS: The top 15 journals with a strong clinical emphasis based on Impact Factor (Clarivate Analytics) calculated by the 2018 Journal Citation Reports were identified for orthopaedic surgery, general surgery (and all general surgical subspecialties), and internal medicine (with representative internal medicine subspecialties). Clinical publications with their primary editorial office located in the United States led predominantly by physicians or basic scientists were eligible for inclusion. The members of an editorial board were identified from the journals' websites. The gender of editors with gender-neutral names (and editors whose gender we considered uncertain) was identified by an internet search for gender-specific pronouns and/or pictures from an institutional profile. Fisher exact tests and t-tests were used to analyze categorical and continuous variables, respectively. Significance was set at p < 0.05. RESULTS: Of the editors analyzed, women made up 9% (121 of 1383) of editorial boards in the orthopaedic journals with the highest Impact Factors, compared with 21% (342 of 1665) of general surgery journals (p < 0.001) and 35% (204 of 587) of internal medicine journals (p < 0.001). The overall mean composition of editorial boards of orthopaedic journals was 10% ± 8% women, compared with that of general surgery, which was 19% ± 6% women (p < 0.001), and that of internal medicine, which was 40% ± 19% women (p < 0.001). CONCLUSION: Women make up a smaller proportion of editorial boards at orthopaedic surgery journals than they do at general surgery and internal medicine journals. However, their representation appears to be comparable to the proportion of women in orthopaedics overall (approximately 6%) and the proportion of women in academic orthopaedics (approximately 19%). Ways to improve the proportion of women on editorial boards might include structured mentorship programs at institutions and personal responsibility for championing mentorship and diversity on an individual level. CLINICAL RELEVANCE: Increasing representation of women on editorial boards may improve the diversity of perspectives and quality of future published research, generate visible role models for young women considering orthopaedics as a career, and improve patient care through enriching the diversity of our specialty.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

BACKGROUND: Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures. METHODS: Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]. RESULTS: Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients. CONCLUSIONS: Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Is methylmethacrylate toxic during pregnancy and breastfeeding?--- a systematic review.

INTRODUCTION: Methyl methacrylate (MMA) is commonly used in the fields of dentistry and orthopaedic surgery. However, there remain concerns for the occupational hazards of MMA, particularly during pregnancy and breastfeeding. METHODS: We performed a systematic review of studies on effects that MMA may have in pregnancy in the context of exposure during orthopaedic surgery and dentistry. Review articles, studies lacking statistical data, single case reports and other evidence level V studies were excluded. RESULTS: Nine studies were included. One basic science study demonstrated an increase in neuronal cell lysis and shrunken cell bodies when neocortical neurons were exposed to MMA monomer. Three animal studies exposed pregnant rodents to MMA via intraperitoneal injection or inhalation. Exposed fetuses in two studies had an increase in gross abnormalities such as hemangiomas, while there was no increase in teratologic effects in the third study. In dental workers exposed to MMA, two retrospective cohort studies did not find a statistically significant increase in birth defects or miscarriage. After exposure to MMA during total joint arthroplasty, two studies found that MMA levels were undetectable in the mothers' serum or breast milk. One study measuring the airborne levels of MMA during simulated joint arthroplasty found that concentrations never exceeded 1% of the recommended limit set forth by the Occupational Safety and Health Administration (OSHA). CONCLUSIONS: Potential teratologic effects of MMA cannot be excluded by existing evidence. However, the typical MMA exposure levels for dental and orthopaedic personnel appear to be substantially less than currently proposed exposure limits.