Physeal Bar Formation After Pediatric Medial Malleolus Fractures.

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Potential limitations of measuring ambulatory activity of part-time wheelchair users: a comparative study of two research grade activity monitors.

Objective.Research grade activity monitors such as the StepWatch Activity Monitor (SAM) and Actigraph have been shown to be highly accurate for the assessment of ambulatory activity, but some individuals function in the community using a combination of both walking and wheelchair activity. The purpose of this study was to assess the accuracy of the SAM and Actigraph at not detecting ambulatory activity, during wheelchair activities at two intensity levels.Approach.Two independent cohorts were tested while simultaneously wearing a SAM and Actigraph on the ankle. Group 1 consisted of twelve adults performing a six-minute push test (6MPT). Group 2 were eighteen members of an adolescent wheelchair basketball team tested during a scrimmage/practice and regional tournament. Visual observation was used to confirm the number of ambulatory steps taken during testing was zero.Main results.The average number of 'steps' detected during a 6MPT was 19 ± 25 (range: 0-85) with the Actigraph. No 'steps' were detected using the SAM in Group 1. In Group 2, the average 'step' count during basketball practice was 1421 ± 750 (range: 612-2798) using the Actigraph and 1363 ± 1238 (range: 84-3462) using the SAM, and correlated with playing time, despite the leg/ankle being strapped down. Similar findings were observed during the wheelchair basketball regional tournament.Significance.Caution should be heeded when utilizing these activity monitors in individuals with disabilities who participate in wheelchair sports. Additional written activity logs should be used to exclude periods of time during which high acceleration wheelchair sporting activity occurs, or study participants should be fully educated in removing the activity monitors during non-ambulatory wheelchair sports.

Normative dataset selection affects gait profile scores of children with cerebral palsy.

INTRODUCTION: The Gait Profile Score (GPS) requires a comparative dataset, to identify altered mechanics in persons with a gait abnormality. This gait index has been shown to be useful for identifying gait pathology prior to the assessment of treatment outcomes. Though studies have shown differences in kinematic normative datasets between different testing sites, there is limited information available on the changes in GPS score based on normative dataset selection. The aim of this study was to quantify the influence of normative reference data from two institutions, on the GPS and Gait Variable Scores (GVS), calculated on the same group of patients with Cerebral Palsy. METHODS: Seventy patients (Avg. age: 12.1 ± 2.9) diagnosed with CP underwent gait analysis during walking at a self-selected speed at Scottish Rite for Children (SRC). GPS and GVS scores were determined using normative kinematic data at a self-selected speed from, 83 typically developing children ages 4-17 from Gillette, and the same age range of children from SRC's normative dataset. Average normalized speed was compared between institutions. Signed rank tests were performed on the GPS and GVS scores using each institution's dataset. Spearman's correlations between scores using SRC and Gillette were determined within GMFCS level. RESULTS: Normalized speed was comparable between each institution's datasets. Within each GMFCS level, significant differences when using SRC vs. Gillette were found in most scores (p < 0.05). Scores were moderately to strongly correlated within each GMFCS level (range ρ = 0.448-0.998). CONCLUSIONS: Significant statistical differences were found in GPS and GVS scores but were within the range of previously reported variation across multiple sites. Caution and consideration may need to be taken when reporting GPS and GVS scores that are calculated utilizing different normative datasets as these scores may not be equivalent.

Predictors of appointment adherence following operative treatment of pediatric supracondylar humerus fractures: which patients are not following up?

This study aims to identify characteristics associated with poor appointment adherence after surgical stabilization of supracondylar humerus fractures (SCHFX) in children. A retrospective review of 560 consecutive, surgically managed patients with SCHFX from 2010 to 2015 was performed. One missed follow-up appointment was classified as 'low adherence', whereas missing two or more appointments was classified as 'very low adherence'. Demographics, insurance status, estimated family income and distance from clinic were analyzed to identify differences in variables between adherent and low-adherent groups. Of 560, 121 (21.8%) missed one follow-up visit and 39/560 (7.1%) missed more than two visits. Age, gender, distance traveled, insurance status and primary language were nonpredictive. Estimated income <$50 000 was associated with a >200% increase in low adherence vs patients with estimated income >$50 000 (9.3 vs 3.8%; P = 0.012). African American patients had significantly lower adherence vs patients of other races (47.5 vs 19.6%; P < 0.0001). Ethnicity remained the only significant factor correlated to adherence after multivariate analysis. African Americans were three times more likely demonstrate low adherence (P = 0.0014). Ethnicity and estimated income <$50 000 were predictors of missing two or more visits. African American patients were four times more likely to miss two or more visits [odds ratio (OR), 4.17; P = 0.0026] than others; estimated income <$50 000 was associated with a two-fold increase in missing two or more visits (OR, 2.33; P = 0.035). By identifying at-risk patient populations, healthcare systems can adopt strategies to remove barriers of accessing follow-up care.

Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study.

BACKGROUND: Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM. METHODS: Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures. RESULTS: Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures. CONCLUSIONS: The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients. LEVEL OF EVIDENCE: Level III.

Vascular examination predicts functional outcomes in supracondylar humerus fractures: a prospective study.

PURPOSE: This article prospectively examines the functional outcome measures following management of vascular insult secondary to paediatric supracondylar humerus fractures (SCHFX) using validated outcome measures. METHODS: The three-year, prospective, IRB-approved study consecutively enrolled operative SCHFX patients. Clinical data included presence and symmetry of the radial pulse in injured and uninjured extremities, Doppler examination of non-palpable (NP) pulses and perfusion status of the hand. Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Measures were used to assess functional outcome at final follow-up. Multiple regression analysis was used to determine the relationship between the presence of a vascular abnormality and functional outcome while controlling for other injury parameters. RESULTS: A total of 146/752 enrolled patients (mean age 6.8 years; range 2 years to 13 years) completed functional outcome measures at final follow-up. Of these, 20 (14%) patients had abnormal vascular exams at presentation: nine (6%) with palpable asymmetric pulse and 11 (7.5%) with NP pulse. Of those with NP pulses, nine/11 (6%) were Dopplerable and two (1.5%) lacked identifiable Doppler signal. Patients with a symmetric, palpable pulse demonstrated better PODCI pain and comfort scores (95.2 versus 85.2) (p < 0.0001), and QuickDASH scores (10.9 versus 21.6) (p < 0.007) compared to those with any abnormal vascular examination. Patients with palpable pulses, regardless of symmetry, demonstrated significantly higher PODCI pain and comfort scores (94.6 versus 84.7) (p < 0.003) than NP pulses. CONCLUSIONS: In children with operative SCHFX, an abnormal vascular examination at presentation is predictive of poorer outcomes in pain and upper extremity function. A palpable pulse, versus NP, is predictive of better pain and comfort at final follow-up. LEVEL OF EVIDENCE: II.

Pathologic arterial changes in neurovascularly intact Gartland III supracondylar humerus fractures: a pilot study.

This pilot study was performed to describe changes in arterial flow in completely displaced neurovascularly intact Gartland III pediatric supracondylar humerus fractures using Duplex ultrasonography. This is a prospective study of 11 Gartland type III supracondylar humerus fractures with no cortical continuity but with palpable radial pulse and normal neurologic examination. Duplex ultrasonography was performed on injured and uninjured arms, both preoperatively and postpinning, and interpreted by a board-certified pediatric radiologist. Degree of artery stenosis and peak systolic velocity (PSV) of arterial flow were recorded from the duplex. Ultrasound wrist/brachial indexes (WBI) were calculated using the higher value of the radial/brachial or the ulnar/brachial index. Only three patients had normal Duplexes without stenosis and with flow comparable in the brachial, radial, and ulnar arteries of the affected arm, compared to the unaffected arm, both preoperatively and postpinning. One group of six patients had brachial artery stenosis at the fracture site when compared to the artery proximal to the fracture site, increased PSV at the fracture site compared to proximal to the fracture site, and the WBI was variable when compared to the contralateral side. A third group of two patients also had brachial artery stenosis at the fracture site but had decreased PSV and decreased WBI compared to the contralateral side. Type III supracondylar humerus patients with a normal neurovascular examination may have abnormal Duplex ultrasonography with brachial artery stenosis and elevated peak systolic velocity preoperatively although distal flow remains comparable to the contralateral side. Level of evidence: prognostic - Level II.

Real-Time Monitoring with a Controlled Advancement Drill May Decrease Plunge Depth.

BACKGROUND: Although drill use is fundamental to orthopaedic surgery, the risk of plunging past the far cortex and potentially damaging the surrounding soft tissues remains unavoidable with conventional drilling methods. A dual motor drill may decrease that risk by providing controlled drill-bit advancement and real-time monitoring of depth and energy expenditure. We hypothesized that using the dual motor drill would decrease plunge depth regardless of the user's level of experience. METHODS: Sixty-six subjects of varying operative experience (20 attending orthopaedic surgeons, 20 orthopaedic surgery residents, and 26 senior medical students) drilled 3 holes with a conventional drill and 3 holes with a dual motor drill in a bicortical Sawbones block set in ballistic gel. The depth of drill penetration into the ballistic gel was measured for each hole using a digital caliper. RESULTS: Overall, subjects plunged less with the dual motor drill (0.9 mm) than with the conventional drill (4.2 mm) (p < 0.001). This finding was consistent within each group: attending surgeons (0.9 compared with 3.2 mm; p = 0.02), residents (1.0 compared with 3.0 mm; p < 0.001), and students (0.7 compared with 6.0 mm; p < 0.001). Plunge depths were also stratified into 3 categories: 0 to <2 mm, 2 to 5 mm, and >5 mm. Using the dual motor drill, subjects were more likely to plunge <2 mm (97% plunged, on average, 0 to <2 mm and 3% plunged, on average, 2 to 5 mm), whereas subjects were more likely to plunge deeper with the conventional drill (27% plunged, on average, 0 to <2 mm, 45% plunged, on average, 2 to 5 mm, and 27% plunged, on average, >5 mm). Notably, no subject plunged ≥2 mm on the third attempt with the dual motor drill. Attending surgeons (p = 0.02) and residents (p = 0.01) plunged less than students with the conventional drill. There was no significant difference between attending surgeons and residents with the conventional drill (p = 0.96). There was no significant difference in plunge depth between groups using the dual motor drill. CONCLUSIONS: The dual motor drill significantly decreased plunge depth for both surgically experienced and inexperienced subjects. Although inexperienced subjects performed worse with the conventional drill than those with experience, there was no difference in their performance with the dual motor drill. CLINICAL RELEVANCE: Use of a controlled advancement drill may decrease the chance of plunge-related neurovascular injury during in vivo drilling.

Biomechanical Analysis of Retrograde Flexible Intramedullary Nail Constructs in a Simulated Pediatric Femur Fracture Model.

BACKGROUND: Various flexible intramedullary nail (FIMN) constructs for pediatric femur fractures are described; however, no biomechanical study has compared stability of medial-lateral entry versus all-lateral entry retrograde nailing. Our purpose is to compare the rotational and bending stiffness of 2 different FIMN constructs and 2 different materials in a simulated pediatric femur fracture model. METHODS: Eighty adolescent-sized composite femurs were used to simulate transverse (40 femurs) and oblique (40 femurs) mid-diaphyseal fractures. Retrograde FIMN of the femurs was performed using either 3.5 mm titanium (Ti) or 3.5 mm stainless-steel (SS) flexible nails in 2 configurations: 2 "C"-shaped nails (CC) placed through medial and lateral entry sites or 1 "C"-shaped nail and 1 "S"-shaped nail (CS) placed through a single lateral entry site. Models were first tested in 10 cycles of axial rotation to ±1 N m of torque at a rate of 0.5 degrees/s under 36 kg of compression. Axial compression was performed and bending stiffness defined as the force required to achieve 10 degrees varus at the fracture site. RESULTS: No differences were noted in rotational stiffness comparing Ti and SS nails regardless of nail configuration or fracture pattern. Comparable rotational stability was found for CC and CS configurations with SS implants for both fracture patterns. The CS construct (0.60 N m/degree) was stiffer in rotation than the CC construct (0.41 N m/degree) with Ti implants in the transverse fracture model (P<0.005). SS nails provided greater bending stiffness than Ti nails in both oblique and transverse fracture patterns, regardless of nail construct. The all-lateral entry (CS) construct demonstrated statistically significant greater bending stiffness regardless of implant material or fracture pattern (P<0.03). CONCLUSIONS: An all-lateral entry (CS) FIMN construct demonstrated greater bending stiffness in both fracture patterns and materials. Ti and SS implants have comparable rotational stiffness in all fracture patterns and materials; however, SS nails were superior at resisting bending forces in both fracture patterns. CS nail configuration and SS implants demonstrated superior bending stiffness and rotational stiffness when compared with the more commonly used CC construct and Ti implants. LEVEL OF EVIDENCE: NA (biomechanical study).

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures.

BACKGROUND: It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces. METHODS: Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion. RESULTS: In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type. CONCLUSIONS: Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures. LEVEL OF EVIDENCE: Level II-comparative biomechanical study.

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons.

BACKGROUND: Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons. METHODS: We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy. RESULTS: Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy. CONCLUSIONS: An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population. LEVEL OF EVIDENCE: Level III-retrospective cohort.

Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS: This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS: A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS: Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE: Level II-therapeutic.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds.

BACKGROUND: Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures. METHODS: An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. RESULTS: A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients. CONCLUSIONS: Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion. LEVEL OF EVIDENCE: Therapeutic Level III.

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures.

PURPOSE: The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures. METHODS: An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes. RESULTS: In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation. CONCLUSIONS: In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal." LEVEL OF EVIDENCE: Level III.

Quengel Casting for the Management of Pediatric Knee Flexion Contractures: A 26-Year Single Institution Experience.

BACKGROUND: Quengel casting was introduced in 1922 for nonsurgical treatment of knee flexion contractures (KFC) associated with hemophilic arthropathy. It consists of an extension-desubluxation hinge fixed to a cast allowing for gradual correction of a flexion deformity while preventing posterior tibial subluxation. The purpose of this study is to report 1 center's experience with this technique for the treatment of pediatric KFC. METHODS: A retrospective review was conducted over a 26-year period. All patients with KFC treated with Quengel casting were included. Demographic data, associated medical conditions, adjunctive soft tissue releases, complications, and the need for late surgical intervention were recorded. Tibiofemoral angle measurements in maximal extension were recorded at initiation and termination of casting, 1-year follow-up, and final follow-up. Success was defined as no symptomatic recurrence of KFC or need for subsequent surgery. RESULTS: Eighteen patients (26 knees) were treated for KFC with Quengel casting. Average age at initiation of casting was 8.1 years with average follow-up of 59.9 months. Fifteen knees (58%) underwent soft tissue releases before casting. An average of 1.5 casts per knee were applied over an average of 23.9 days. Average KFC before casting was 50.6 degrees (range, 15 to 100 degrees) which improved to 5.96 degrees (0 to 40 degrees) at cast removal (P<0.00001). Sixteen patients (22 knees) had 1-year follow-up or failed casting before 1 year. Of these, 11 knees (50%) had a successful outcome. Residual KFC of those treated successfully was 6.8 degrees (range, 0 to 30 degrees) at 1 year and 8.2 degrees (range, 0 to 30 degrees) at final follow-up, averaging 71.4 months (P=0.81). Of the 11 knees deemed failures, all had recurrence of deformity within an average of 1 year from cast removal. Surgical release before Quengel casting did not improve the chances for success (P=0.09). CONCLUSIONS: Quengel casting can improve pediatric KFC an average of 44.2 degrees with minimal complications. Although 50% of treated patients will demonstrate significant recurrence or need later surgery, the majority of those treated successfully have durable results at intermediate term follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Osteomyelitis is Commonly Associated With Septic Arthritis of the Shoulder in Children.

PURPOSE: To describe the clinical presentation, management, and outcomes of surgically treated septic arthritis of the shoulder in a pediatric population. METHODS: A retrospective chart review over 5 years of children with operatively managed septic arthritis of the shoulder was completed. Demographics, clinical presentation, symptoms duration, antibiotic regimen and duration, number of surgical procedures, and evaluation of laboratory value improvements were collected. Pretreatment and final radiographs were assessed. Causative organisms were reviewed. Patients were stratified in age groups to determine clinical variability based upon patient age. RESULTS: A total of 22 children, ages 15 days to 14 years (average 37.3 mo), were treated for septic arthritis of the shoulder from 2006 to 2010 at a single pediatric institution. All patients were managed with open anterior arthrotomy at an average of 1.95 days after initial orthopaedic consultation (range, 0 to 15 d). Multiple presenting signs were noted; the most common was decreased use (59%). Average admission laboratory values include C-reactive protein 10.6 (range, 0.3 to 41.6), erythrocyte sedimentation rate 62.8 (range, 11 to 107), and white blood cell count 14.9 (range, 5.9 to 31.7). Initial radiographs were read as normal in 12 patients, concern for osteomyelitis in 5, cortical irregularity in 4, effusion in 3, and neoplasm in a single child. Nineteen patients had a preoperative magnetic resonance imaging and 15 demonstrated an effusion, 15 had evidence of humeral osteomyelitis, 5 had a subperisoteal abscess, and 4 had soft tissue abscesses. Eight patients remained culture negative. The most commonly identified organism was methcillin-resistant Staphylococcus aureus (MRSA) (22.7%). The patients under 12 months of age revealed more diverse organisms at culture and were less likely to have MRSA. All patients averaged 1.55 (range, 1 to 5) surgical procedures and had an average hospital stay of 13.5 days. Intravenous antibiotics averaged 16.3 days followed by an average of 34 days of oral treatment. MRSA patients were significantly more likely to require multiple operations to eradicate the infection (P<0.02) and had a longer duration of intravenous antibiotic use (P<0.003). MRSA patients were more likely to have abnormal radiographs at final follow-up (P<0.03). CONCLUSIONS: Septic arthritis of the shoulder in children is commonly associated with adjacent osteomyelitis. Pediatric septic arthritis of the shoulder due to MRSA bacteria can have a more virulent course than other bacterial causes, but is a less commonly identified organism in the youngest patients. SIGNIFICANCE: To our knowledge, this is one of the largest series published concerning the treatment, course, and outcomes of pediatric septic arthritis of the shoulder. LEVEL OF EVIDENCE: Level III-therapeutic.

Avascular Necrosis in the Contralateral Hip in Patients With Congenital Femoral Deficiency: A Report of 3 Cases.

BACKGROUND: Congenital femoral deficiency is an uncommon clinical entity. We report 3 patients who developed avascular necrosis of the hip in the long (normal) leg during longitudinal observation and/or treatment of congenital femoral deficiency. METHODS: Patients were identified in limb length discrepancy clinic and their charts were retrospectively reviewed for clinical and radiographic data collection. RESULTS: We describe the occurrence of idiopathic avascular necrosis in the normal limb in patients being followed for limb length discrepancy. CONCLUSIONS: Although no conclusion could be drawn about the etiology of the avascular necrosis, we describe a previously undocumented relationship between congenital femoral deficiency and avascular necrosis in the contralateral hip. This occurred in our congenital femoral deficiency population at a rate higher than expected compared with published incidences of avascular necrosis of the hip in children. LEVEL OF EVIDENCE: Level IV-case series.

Two Techniques for Retrograde Flexible Intramedullary Fixation of Pediatric Femur Fractures: All-Lateral Entry Versus Medial and Lateral Entry Point.

BACKGROUND: Multiple techniques for flexible intramedullary nailing (FIMN) of pediatric femur fractures have been described. To our knowledge, no study has compared combined medial-lateral (ML) entry versus all-lateral (AL) entry retrograde nailing. This study compares surgical outcomes, radiographic outcomes, and complication rates between these 2 techniques. METHODS: A retrospective review of a consecutive series of patients treated by retrograde, dual FIMN of femur fractures was performed from 2005 to 2012. Demographics and operative data were recorded. Radiographs were analyzed for fracture pattern, fracture location, percent canal fill by the nails, as well as shortening and angulation at the time of osseous union. Rates of symptomatic implants and their removal were noted. Data were compared between patients treated with medial and lateral entry (ML group) nailing and those treated with all-lateral entry (AL group) nailing using the Student t test and correlation statistics. RESULTS: Of the 244 children with femoral shaft fractures treated with retrograde FIMN using Ender stainless steel nails, 156 were in the ML group and 88 were in the AL group. There were no statistical differences in sex (74% vs. 82% males), age (8.0 vs. 8.6 y), weight (29.4 vs. 31.1 kg), or fracture pattern between the 2 groups. The average total anesthesia time was less in the AL group (133 vs. 103 min) (P<0.0001). There was no difference between the techniques in shortening (3.9 vs. 3.0 mm), coronal angulation (2.9 vs. 2.6 degrees), or sagittal angulation (3.3 vs. 2.7 degrees) at union. In the AL group, there was a correlation between canal fill and reduced shortening at union. No differences were found in the presence or degree of varus alignment, procurvatum deformity, or recurvatum angulation between the constructs. There were 5 malunions in the AL group and 9 malunions in the ML group (5.7% vs. 5.8%, P=1). The incidence of having a healed femur fracture with >10 degrees of valgus was higher in the AL group (0% vs. 3.4%) (P=0.04). There were no differences between the groups in the rate of symptomatic implant removal or surgical complications. CONCLUSIONS: The AL entry technique for FIMN of pediatric femur fractures is 30 minutes faster without worse final fracture alignment, additional complications, or increased rates of symptomatic implants. When using the AL technique, specific attention should be paid to percentage of canal fill and ensuring that the fracture is not reduced in a valgus position. LEVEL OF EVIDENCE: Level III-therapeutic.

Fracture Classification Does Not Predict Functional Outcomes in Supracondylar Humerus Fractures: A Prospective Study.

BACKGROUND: Few studies have prospectively assessed functional outcomes after the surgical management of supracondylar humerus fractures (SCHFXs) and the relationship between fracture pattern and ultimate patient outcome has never been prospectively evaluated. The purpose of this study was to prospectively evaluate fracture classification and functional outcome in children with extension SCHFXs using validated outcome measures. METHODS: An Institutional Review Board-approved prospective enrollment of consecutive patients with operative SCHFX was performed over a 3-year period. Fractures were classified by the treating surgeon using the modified Gartland classification. Functional outcome was assessed at final follow-up using the Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcome measure. Patients with flexion-type fractures, multidirectionally unstable fractures and those with <10 weeks follow-up were excluded from analysis. Statistical analysis was used to determine the relationship between fracture classification/pattern and functional outcome. RESULTS: Seven hundred fifty-two patients were enrolled during the study period. One hundred thirty-two patients with extension-type injuries (average age 6.7 y) completed functional outcome measures at an average follow-up of 12.4 weeks. Forty-five (34%) were type II fractures and 87 (66%) were type III fractures. Forty-five (34%) of the fractures were posteromedially displaced, 43 (33%) were posterolaterally displaced, and 44 (33%) were posteriorly displaced without coronal plane deformity. The average PODCI global functioning scale score and QuickDASH scores for the entire cohort were 93.6 and 11.4, respectively, indicating excellent function. No differences in outcome scores were noted between patients with type II and III fractures. No difference in outcome was identified based upon direction of fracture displacement. CONCLUSIONS: This is the first study to prospectively analyze fracture classification and functional outcome using validated outcome measures following the operative treatment of pediatric extension-type SCHFX. Children generally have excellent functional outcomes following the operative treatment of SCHFX. Garland classification and direction of displacement do not influence functional outcomes. LEVEL OF EVIDENCE: Level II-therapeutic.