Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients.

BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.

Progressive Elbow Magnetic Resonance Imaging Abnormalities in Little League Baseball Players Are Common: A 3-Year Longitudinal Evaluation.

BACKGROUND: Prior studies have revealed magnetic resonance imaging (MRI) evidence of elbow pathology in single-season evaluation of competitive youth baseball players. The natural history of these findings and risk factors for progression have not been reported. PURPOSE: To characterize the natural history of bilateral elbow MRI findings in a 3-year longitudinal study and to correlate abnormalities with prior MRI findings, throwing history, playing status, and physical examination. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of Little League players aged 12 to 15 years was performed. All players had preseason and postseason bilateral elbow MRI performed 3 years before this study. Players underwent repeat bilateral elbow MRI, physical examination, and detailed assessment of throwing history, playing status, and arm pain. Imaging was read by a blinded musculoskeletal radiologist and compared with prior MR images to assess for progression or resolution of previously identified pathology. RESULTS: All 26 players who participated in the previous single-season study returned for a 3-year assessment. At the completion of the study, 15 players (58%) had dominant arm MRI pathology. Eighty percent (12/15 players) of MRI findings were new or progressive lesions. Players with postseason MRI pathology at the beginning of the study were more likely to have MRI pathology at the 3-year follow-up than players with previously normal postseason MRI (P < .05), although 6 of the 14 players (43%) with previously normal MRI developed new pathology. Year-round play was a significant predictor of tenderness to elbow palpation (P = .027) and positive MRI findings at 3 years (P = .047). At the 3-year follow-up, 7 players (27%) reported having throwing elbow pain and 3 had required casting. Additionally, differences were noted in the dominant arm's internal and external rotation in those that continued to play baseball (P < .05). CONCLUSION: Dominant elbow MRI abnormalities are common in competitive Little League Baseball players. Year-round play imparts significant risk for progression of MRI pathology and physical examination abnormalities.

The Curse of the All-Star Team: A Single-Season Prospective Shoulder MRI Study of Little League Baseball Players.

BACKGROUND: Throwing guidelines have been implemented in Little League baseball in an attempt to minimize injuries in young baseball players. We hypothesized that playing pitcher or catcher and increased innings played during the season would result in dominant shoulder magnetic resonance imaging (MRI) abnormalities. METHODS: A prospective evaluation of Little League players aged 10 to 12 years was performed. Players recruited before the start of the season underwent bilateral preseason and dominant shoulder postseason MRI, physical examination, and questionnaires addressing their playing history and arm pain. Innings played, player position, pitch counts, and all-star team selection were recorded. RESULTS: In total, 23 players were enrolled. The majority (19/23, 82.6%) were right-handed and 16 of 23 (69.6%) played at least 10 innings as pitcher or catcher. Sixteen were selected for the all-star team. Fourteen players (60.9%) had positive dominant shoulder MRI findings not present in their nondominant shoulder. Eight players (34.8%) had new or worsening postseason MRI findings. Thirteen players (81.3%) selected to the all-star team had abnormal MRI findings whereas only one (14.3%) player not selected as an all-star had MRI abnormalities (P=0.005). Year-round play (P=0.016), innings pitched (P=0.046), innings catcher (P=0.039), and number of pitches (P=0.033) were associated with any postseason MRI abnormality, but not for new or worsening MRI changes. Single sport athletes and players playing for multiple teams were significantly more likely to have abnormal MRI findings (P=0.043 and 0.040, respectively) when compared with multisport athletes playing on a single team. CONCLUSIONS: MRI abnormalities involving the dominant shoulder are common in Little League baseball players and often develop or worsen during the season. Contrary to our hypothesis, MRI abnormalities were not associated with player position and pitch counts. Instead, they were most closely associated with year round play, single sports participation, and all-star team selection. The increased demands required for all-star selection comes at a price to the young athlete as the majority of players selected for this honor had abnormal MRI findings in their throwing shoulder while few non all-stars demonstrated such pathology. LEVEL OF EVIDENCE: Level II.

Shoulder MRI Abnormalities in Asymptomatic Little League Baseball Players.

BACKGROUND: Youth baseball is extremely popular in the United States, but it has been associated with shoulder pain and injury. The incidence of shoulder abnormalities in this athletic population has yet to be defined. PURPOSE: To examine abnormalities noted on magnetic resonance imaging (MRI) in the shoulders of asymptomatic Little League baseball players and to correlate these findings with the players' throwing history and physical examinations. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 23 Little League baseball players aged 10 to 12 years were recruited. All players underwent a comprehensive physical examination and responded to a questionnaire addressing their playing history and any arm or shoulder pain. Bilateral shoulder MRIs were performed and read in a blinded manner by 2 radiologists. Responses on the questionnaire and physical examination findings were compared between participants with and without positive MRI findings through use of chi-square test and analysis of variance. RESULTS: The dominant arm was 8.5 times more likely to have an abnormality on MRI compared with the nondominant arm. In all, 12 players (52%) had 17 positive MRI findings in their throwing shoulder that were not present in their nondominant shoulder. These findings included edema or widening of the proximal humeral physis (n = 5), labral tear (n = 4), partial rotator thickness tear (n = 4), acromioclavicular joint abnormality (n = 2), subacromial bursitis (n = 1), and cystic change of the greater tuberosity (n = 1). Two primary risk factors were associated with an abnormal MRI: year-round play and single-sport athletes focusing solely on baseball (P < .05). Players with no risk factors, 1 risk factor, and both risk factors had a 25%, 71%, and 100% chance, respectively, of having an abnormal MRI. A majority of players (61%) had previously experienced shoulder pain, especially pitchers throwing curveballs and sliders (P < .05), but this was not associated with an abnormal MRI. CONCLUSION: Abnormalities seen on MRI involving the shoulder are common in Little League baseball players, especially those who are single-sport athletes playing year-round.

Is ultrasound screening for DDH in babies born breech sufficient?

PURPOSE: To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations. METHODS: A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parameters-if there was greater than 10° difference in side-to-side abduction or symmetric abduction of less than 60°. RESULTS: Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months. CONCLUSIONS: Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.

Predicting initial treatment failure of fiberglass casts in pediatric distal radius fractures: utility of the second metacarpal-radius angle.

PURPOSE: Recent literature comparing the effectiveness of above-elbow and below-elbow plaster casts appears to suggest that either cast type offers adequate immobilization for distal radius and ulna fractures. The idea that an appropriate mold placed on the cast is the most significant determinant of successful immobilization and, thereby, patient outcome has also been elucidated. The purpose of this study was to compare the effectiveness of above-elbow versus below-elbow fiberglass casts in maintaining distal radius/ulna fracture reduction and to identify factors associated with treatment failures. METHODS: We reviewed the radiographs and clinical data of 253 children with distal third forearm fractures requiring reduction under conscious sedation or a hematoma block. Outcome measures included rates of re-manipulation, loss of reduction, and cast complications. RESULTS: One hundred and nineteen children were treated with below-elbow fiberglass casts and 134 were treated with above-elbow fiberglass casts based on a clinical pathway created before the study period. There were no differences between the two groups in age, weight, fracture pattern, percentage of both-bone fractures, and initial fracture angulation. Of the 253 fractures in the study, 38 (15%) were considered to have less than ideal outcomes. There were no differences between the 'ideal' and 'non-ideal' groups in age, fracture pattern, presence of ulna fracture, cast index, or cast type. All immediate post-reduction measures (anterior-posterior [AP] and lateral displacement/angulation) were significantly correlated with treatment outcome, except angulation on AP films. The magnitude of reduction as measured by a newly described variable, the angle between the second metacarpal and long axis of the radius in the AP projection, was significantly correlated with treatment failure (r = -0.139, P = 0.027). Binary logistic regression was performed and demonstrated that the success of the reduction, as determined by the AP radiograph second metacarpal-radius angle, was a significant predictor of treatment success (odds ratio 1.6, P < 0.001). Also, the change in lateral view angulation post-reduction was a significant predictor of treatment failure based on regression (odds ratio 1.2, P = 0.004). The above-elbow cast group had a slightly greater cast index (0.80) compared to the below-elbow cast group (0.77) (P = 0.003). Whereas below-elbow fiberglass casts appear to be equally effective in immobilizing pediatric distal third forearm fractures as above-elbow fiberglass casts, it seems that they have an increased risk for poor molding, particularly with regards to ulnar deviation. We did not find an association between the treatment 'failure' and cast index, likely because the number of poor molds (cast index >0.8) was nearly equal in each group (above-elbow with 61 and below-elbow with 45). However, the mold seen on the AP radiograph as determined by the second metacarpal-radius angle was a reproducible radiographic predictor of treatment success. If molded with ulnar deviation (second metacarpal-radius angle >0 degrees ), the outcome was considered to be ideal in 86.7% of cases compared to only 74.4% when it was <0 degrees . CONCLUSION: We agree with prior studies suggesting the equal efficacy of below-elbow versus above-elbow casts in distal radius and ulna fracture treatment using either plaster or fiberglass, but wish to emphasize the importance of not only the cast index, but also the ulnar deviation mold (for most dorsally displaced fractures), as measured by the second metacarpal-radius angle.