Patient and Caregiver Impressions of the Impact of Madelung Deformity: A CoULD Registry Analysis.

PURPOSE: This study seeks to investigate demographics of patients with Madelung deformity in a large, geographically diverse sample and understand patient and caregiver perceptions of the impact of this condition. We hypothesized that patients with untreated Madelung deformity have greater pain and lower function compared to the normal population but are less affected than the chosen control group, namely, patients with proximal radioulnar synostosis (PRUS). METHODS: This retrospective study queried the Congenital Upper Limb Differences (CoULD) Registry, a multicenter registry of patients treated in tertiary care pediatric hospitals. We searched patients enrolled as of July 2022 and identified 3,980 total patients and 66 (1.7%) with a diagnosis of Madelung deformity. We reviewed demographics and Patient-Reported Outcomes Measurement Information System (PROMIS; peer relations, depressive symptoms, pain interference, and upper extremity function domains) scores at time of enrollment. We used a matched cohort comparison with propensity scoring for 50 patients with Madelung deformity and 50 patients with PRUS (control cohort). RESULTS: Patients with Madelung deformity presented at an average age of 13.1 years (± 2.1 years). Ninety-eight percent were female, and 82% were White. Seventy-four percent had distal radius-only deformity. Upper extremity PROMIS scores in both the Madelung deformity and the PRUS groups were significantly "worse" than normal, confirming our hypothesis. The Madelung deformity and PRUS cohort scores were not consistently different from one another. PROMIS scores from all other domains, including pain interference, were similar to, or better than normal for both groups, disproving the second part of our hypothesis. CONCLUSIONS: Patients with Madelung deformity averaged 13 years of age and were nearly all female, and the majority had only distal involvement of the radius. Patients with Madelung deformity had lower function based on PROMIS scores, similar to the control cohort, whereas all other PROMIS measures were similar to or better when compared to normal values. Pain interference scores in both cohorts were lower than normal values. Patients with Madelung deformity have decreased function, similar to the comparative cohort of patients with PRUS, but do not present with increased pain. TYPE OF STUDY/LEVEL OF EVIDENCE: Symptom prevalence III.

Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Outcomes of Adolescent T-condylar Fractures: Kids Do Not Always Make You Look Good.

BACKGROUND: Optimal treatment for pediatric and adolescent T-condylar fractures remains poorly understood. We sought to assess how functional outcomes and range of motion (ROM) after surgical fixation of T-condylar fractures are affected by patient and surgical factors. METHODS: This is a retrospective cohort study of 52 patients with operatively treated T-condylar fractures at a single tertiary pediatric referral center between 2003 and 2021. All patients younger than 18 at the time of injury with a radiographically confirmed diagnosis were included. RESULTS: Fifty-two T-condylar fractures were included, with a mean patient age of 12.9 years (SD, 2.8). The cohort was 65% male. Nine (19%) fractures were open, 46% (24/52) were AO type C2, and 33% (17/52) occurred in skeletally mature individuals. The surgical approach was through olecranon osteotomy in 29% (15/52) of patients, and fixation included anatomically specific plates and screws in 42% (22/52) of patients. In our cohort, 46% (24/52) achieved good outcomes based on Jarvis ROM criteria and 42% (22/52) achieved good to excellent results based on Roberts functional criteria. The median loss of ROM was 58 degrees at 6 weeks, 20 degrees at 3 and 6 months, and 8 degrees at 1 year postoperatively. We observed a complication rate of 54% (28/52). Patients undergoing adult-type plate fixation had better postoperative range of motion at 6 weeks (ROM loss 52 vs. 80 degrees, P =0.03) and 3 months (10 vs. 35 degrees P =0.004) compared with pediatric-type fixation and trended towards better functional outcomes. We did not identify significant differences in functional outcome scores or complication rates with respect to surgical approach or skeletal maturity. CONCLUSIONS: Surgical fixation of pediatric and adolescent T-condylar fractures achieved a good to excellent functional outcome in only a minority of patients (46% Jarvis / 42% Roberts) with a high rate of postoperative complications (54%). Future work is needed to elucidate optimal treatment to minimize complications and achieve the best functional outcomes in these challenging fractures. LEVEL OF EVIDENCE: Level-IV.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences.

PURPOSE: Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities. METHODS: Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected. RESULTS: The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity. CONCLUSIONS: In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers. CLINICAL RELEVANCE: As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Donor-Site Morbidity for Iliac Crest Harvesting for Pediatric Scaphoid Nonunion.

PURPOSE: Screw fixation with iliac crest bone grafting (ICBG) is a well-studied treatment for pediatric scaphoid nonunions. Studies in adults, as well as in pediatric spine fusions, have demonstrated high rates of complications with ICBG, including longer-term donor site pain. We hypothesized that in pediatric patients undergoing ICBG for scaphoid nonunion, the donor site complication rate would be lower than that reported in other populations. METHODS: Records of patients ages 0-18 years at a single institution undergoing surgical reconstruction for scaphoid nonunion from 1995 to 2016 were reviewed. Patient and surgical variables were recorded, including how ICBG was harvested. Donor site complications were recorded, including donor site pain beyond 30 days after surgery, infection, peri-incisional or lower extremity numbness at any point after surgery and reoperation at the donor site at any time point after surgery. RESULTS: During the study period, 119 wrists in 117 patients underwent internal fixation and ICBG for scaphoid nonunion. The average age was 16 years; mean follow-up was 1 year. The majority of wrists (73, 62.9%) underwent harvest of both outer and inner tables of the iliac crest; 38 (31.9%) had only outer table harvested; 5 (4.3%) had only cancellous graft harvested. Ten wrists (8.4%) had a donor site complication. The most common donor site complication was donor site pain beyond 30 days after surgery (5, 4.2%), followed by numbness (4, 3.4%). No infections, seromas, or reoperations at the donor site occurred. In comparison to those subjects who did not experience complications, we found no difference based on the age at surgery or the type of graft used. Female patients were more likely to have a recorded complication than males. CONCLUSIONS: Donor site morbidity for iliac crest grafting in pediatric patients undergoing scaphoid nonunion surgery appears to be lower than that previously reported in adult patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reliability of the Masada Classification for Forearm Involvement in Patients With Hereditary Multiple Osteochondromas (HMO).

BACKGROUND: Classifications describing forearm lesions in patients with Hereditary Multiple Osteochondromatosis (HMO) have been used to recommend surgical intervention and stratify outcomes; however, there is no consensus on which classification offers greater reliability. The purpose of this study was to determine the reliability of the Masada classification and newer classifications among pediatric hand surgeons. METHODS: One hundred one patients with HMO between June 2014 and October 2019 were enrolled in the Congenital Upper Limb Differences (CoULD) Registry. Of those, 67 patients with 101 forearms were included. Four pediatric hand surgeons from the CoULD study group undertook an online evaluation. Each rater classified radiographs according to the Masada classification. Six weeks later, raters were asked to reclassify images according to the Masada, Gottschalk, and Jo classifications. Rater agreement for these classifications was assessed by estimating Fleiss kappa along with a 95% CI. RESULTS: Interrater agreement for Masada classification after the first reading was poor (κ=0.35; 95% CI=0.30-0.41) across all raters. Interrater agreement across the 4 raters decreased for the Masada classification from the first to the second reading (κ=0.35 vs 0.21; P <0.001). Intrarater agreement for the Masada classification ranged from 0.32 to 0.63 from the first to the second study reading. Gottschalk and Jo classifications yielded significantly better interrater agreement compared with Masada (κ=0.43 vs 0.21; P <0.001). Unclassifiable cases were highest in the Masada classification (34% to 44%) and lower in the Jo (17%) and Gottschalk (14%) classifications. CONCLUSION: Despite wide use, the Masada classification was found to have low reliability when classifying forearm deformities in HMO. Gottschalk offered more options for location, yet lacked deformity description including radial head dislocation. Jo classification offered more locations than Masada and incorporated radial head dislocation in some patterns. Based on the shortcomings in all 3 classification systems, the development of a more inclusive and reliable classification is warranted. LEVEL OF EVIDENCE: Level II; Diagnostic.

Fully displaced pediatric supracondylar humerus fractures: Which ones need to go at night?

Background: Challenges remain in determining which displaced supracondylar humerus fractures are safe to postpone surgical treatment until daylight hours. The purpose of this study is to determine which characteristics can be identified to guide the timing of treatment of supracondylar humerus fractures. Methods: 225 completely displaced Gartland extension type 3/4 supracondylar humerus fractures in healthy patients that presented between 6 am and 7 am were identified. Data were collected retrospectively. Data analysis included univariate, multivariable logistic regression and classification and regression tree analysis. Results: 5% (78/225) underwent surgical treatment the night they presented, while 65% (147/225) were treated the next day. Overall complication rate was 6%, with no difference based on timing of surgery. 12% (28/225) presented with a motor nerve injury, while 6% (14/225) a "pink pulseless" extremity. Statistical analysis found the most reliable radiographic predictor to be the maximum displacement on the anterior-posterior or lateral view. Classification and regression tree analysis developed a clinical algorithm; patients with a "pink pulseless" extremity or motor nerve injury were recommended for surgery overnight, while those with an anterior-posterior or lateral view < 25 mm were recommended for surgery the next day. Conclusion: This study provides guidance on the timing of treatment for displaced supracondylar humerus fractures that present overnight. We provide a simple algorithm with three key clinical predictors for timing of treatment: presence of a "pink pulseless" arm, presence of a motor nerve injury, and displacement of any cortex by at least 25 mm (anterior-posterior or lateral view). This provides a step forward to help practitioners make safer evidenced-based timing decisions for their patients. Level of evidence: Prognostic Study, Level II.

The Impact of Isolated Versus Multiple Osteochondromas: Analysis of the CoULD Registry.

PURPOSE: The burden of upper extremity (UE) osteochondromas on function and self-perception among pediatric patients is unclear. The purpose of our study was to study the impact of osteochondromas in comparison to population norms and to evaluate solitary versus multiple osteochondromas on subjective UE function as measured by patient rated outcomes. METHODS: We utilized the CoULD (Congenital Upper Limb Differences) Registry to review all pediatric patients presenting with osteochondromas between January 2014 and February 2021. Demographic information was collected and patients were classified as having either single or multiple osteochondromas. Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes Data Collection Instrument (PODCI) tools were utilized for assessment. Scores for PODCI subscales of UE function, Pain/comfort, and Happiness and PROMIS domains of UE Function, Pain, Depression, Anxiety, and Peer Relations were reviewed. Differences between groups were analyzed using the Student t test. RESULTS: Ninety-nine patients met inclusion criteria for the study with an average age of presentation of 9.3 years and 61 patients (62%) were male. Overall, patients demonstrated worse UE Function as well as greater Anxiety and Depression in comparison to the population normals on PROMIS assessment. Patients also demonstrated worse patient and parent reported PODCI UE, Sports and Physical Functioning, Pain/Comfort and Global Functioning scores compared with population norms but demonstrated better than average happiness scores. Patients with multiple osteochondromas demonstrated greater PROMIS pain interference and more disability in PODCI Sports and Physical Functioning, Pain/Comfort and Global Functioning compared with those with solitary osteochondromas. CONCLUSION: Patients with UE osteochondromas have worse overall function in comparison to population norms, exceeding established minimally clinically important difference values. In addition, patients with multiple osteochondromas reported more pain and poorer physical function than those with solitary osteochondromas. Physicians should be alert to the physical and psychosocial burden of this disease. LEVEL OF EVIDENCE: Level II-prognostic.

Anxiety surrounding supracondylar humerus pin removal in children.

Purpose: The purpose of this study was to quantify the anxiety experienced by patients undergoing pin removal in clinic following closed reduction and percutaneous pinning for supracondylar humerus fractures. Methods: We prospectively enrolled 53 patients (3-8 years) treated for supracondylar humerus fracture with closed reduction and percutaneous pinning between July 2018 and February 2020. Demographic and injury data were recorded. Heart rate and the Face, Legs, Activity, Cry, and Consolability scale were measured immediately before pin removal and after pin removal, and crossover control values were obtained at the subsequent follow-up clinic visit. Results: All patients experienced anxiety immediately prior to pin removal (95% confidence interval, 94%-100%) with a median Face, Legs, Activity, Cry, and Consolability score of 7 (interquartile range, 6-8). In addition, 98% of subjects experienced an elevated heart rate (95% confidence interval, 88%-100%). Patients experienced a median 73% reduction in Face, Legs, Activity, Cry, and Consolability score and mean 21% reduction in heart rate from prior to pin removal to after pin removal (p < 0.001). All 45 patients who completed their follow-up visit had a control Face, Legs, Activity, Cry, and Consolability score of 0 and a mean control heart rate of 89.7 bpm. Twenty-five of these 45 subjects (56%) had an elevated control heart rate for their age and sex. Mean heart rate prior to pin removal was 36% higher than control heart rate. There were no sex differences detected in Face, Legs, Activity, Cry, and Consolability scores or heart rate. Conclusions: Pediatric patients experience high levels of anxiety when undergoing pin removal following closed reduction and percutaneous pinning for supracondylar humerus fractures. This is an area of clinical practice where intervention may be warranted to decrease patient anxiety. Level of evidence: II.

Comparison of 2 Patient-Reported Outcome Measures in Brachial Plexus Birth Injury: A Systematic Validation Study.

BACKGROUND: Patient-reported outcome (PRO) measures are integral to clinical practice. While new instruments bring updated methodology and delivery methods, they must be compared with existing measures to ensure that they are comparable with currently used instruments and allow ongoing comparison. In this study, we evaluated 2 PRO measures for patients with brachial plexus birth injury (BPBI): the legacy Pediatric Outcomes Data Collection Instrument (PODCI) and the newer Patient-Reported Outcomes Measurement Information System (PROMIS). We hypothesized that the PROMIS and PODCI would be correlated, with high convergent validity, and that PROMIS assessment would have higher discriminant validity and take less time to complete than the PODCI. METHODS: A cross-sectional prospective study was undertaken at a tertiary referral center. Subjects (n = 50) completed the PODCI and PROMIS, both as short form (SF) and computer-adaptive testing (CAT) measures, in randomized order. Patient and parent questionnaires were completed according to subject age. Physicians completed upper-extremity (UE) physical function tests. Correlations between PODCI and PROMIS scores were analyzed to determine convergent validity, UE subscores were analyzed relative to physical function scores to assess discriminant validity, and completion times were calculated to determine survey time to completion. RESULTS: High convergent validity was found between the parent-reported PODCI, PROMIS SF, and PROMIS CAT measures. A ceiling effect was found for the PODCI but not for the PROMIS. The PROMIS CAT had better discriminant validity than either the PROMIS SF or PODCI. Patient and parent outcome scores did not highly correlate. Survey time to completion varied by PRO measure and method of delivery. CONCLUSIONS: There was high convergent validity between the UE domains of the PROMIS and PODCI, with a lower time to completion for the PROMIS SF. Although results show that the PROMIS CAT may take longer to complete, there are notable benefits to its adoption, including high convergent validity with the PODCI and better discriminant validity than the PODCI and PROMIS SF measures.

Closed Reduction and Immobilization of Pediatric Fifth Metacarpal Neck Fractures.

BACKGROUND: There is no clear consensus for the criteria for closed treatment of metacarpal neck fractures. Our objective was to determine whether closed reduction of pediatric fifth metacarpal neck fractures results in a clinically meaningful improvement in radiographic angulation. METHODS: We performed a retrospective cohort study of pediatric patients with fifth metacarpal neck fractures treated with closed reduction. Radiographs were examined for sagittal fracture angulation measured post-reduction, 2 to 14 days post-reduction, and 21 to 35 days post-reduction. We compared the angulation for open versus closed physes, initial fracture angulation greater than or less than 50°, and immobilization in extension versus intrinsic-plus position. RESULTS: Fifty-four subjects were included with an average age of 14.8 years at the time of injury and a mean initial fracture angulation of 42.7°. The improvement in fracture angulation was 8.3° (90% confidence interval [CI], 5.9-10.7) on post-reduction radiographs, 8.5° (90% CI, 6.1-10.9) at 2 to 14 days post-reduction, and 4.3° (90% CI, 1.4-7.2) at 21 to 35 days post-reduction. Subgroup analysis showed that patients with injury angle greater than or equal to 50° had significantly higher mean reductions than those with injury angle less than 50°. In this group, angulation improved 15.6° (90% CI, 8.5-22.7) post-reduction, 15.1° (90% CI, 10.1-20.1) at 2 to 14 days post-reduction, and 16.5° (90% CI, 10.4-22.6) at 21 to 35 days post-reduction. CONCLUSIONS: Closed reduction of pediatric fifth metacarpal neck fractures with initial fracture angulation less than 50° may not meaningfully improve sagittal alignment. For fractures with initial angulation greater than or equal to 50°, closed reduction resulted in clinically important, statistically significant, and lasting improvements of 16.5°.

The fiscal impact of repeat imaging in a pediatric orthopedic clinic.

BACKGROUND: Many patients present to an initial pediatric orthopedic clinic visit without bringing previously obtained x-rays (XRs), leading to repeat imaging, unnecessary radiation exposure, and increased health care costs. Importing images to the picture archiving and communication system and the use of cloud-based medical image-sharing software systems result in the reduction of reimaging rates and health care costs. LOCAL PROBLEM: Unnecessary duplicative XR imaging was recognized in our pediatric orthopedic clinic as an area for quality improvement. Our purpose was to determine the magnitude of the problem and the feasibility of decreasing total visit charges through electronic retrieval of previous XRs. METHOD: Data collection occurred from May 22, 2019, through June 22, 2019, in the orthopedic trauma clinics at the main campus of a quaternary care pediatric hospital in the northeast United States and its three satellite locations. INTERVENTION: The number of patients who did not bring XRs to their initial orthopedic visit and the type of XR ordered were recorded by clinicians. A retrospective chart audit was also completed for comparison. RESULTS: Of 699 new patient visits, 77 (11%) did not bring previous XRs. This resulted in total reimaging charges of $33,326, representing 30%-50% of total visit charges. Retrospective chart audit identified 60% more new patients than the clinicians. CONCLUSIONS: Electronic retrieval of XRs in pediatric orthopedic clinics can decrease duplicative charges, radiation exposure, and health care waste. It can also contribute to successful care of patients via virtual visits in times of restricted access such as a pandemic.

Congenital Upper Limb Differences Registry (CoULD): Registry Inclusion Effect.

PURPOSE: To advance the understanding of the epidemiology and treatment outcomes of congenital upper limb differences, a multicenter registry for Congenital Upper Limb Differences (CoULD) was established. After 4 years of recruitment, we sought to examine whether the relative frequency of congenital conditions compares with prior cross-sectional research and how the data have matured over time by (1) comparing our registry population with previous studies in similar populations and (2) evaluating the change over time of relative frequencies of selected conditions within the CoULD registry cohort, specifically to investigate for registry inclusion effects. METHODS: Data from the 2 founding centers in the CoULD registry were analyzed over a 4-year period. We compared patients included in the CoULD registry against 2 prior studies by matching each condition according to the Oberg-Manske-Tonkin classification system. The relative frequency of 4 representative conditions was calculated to evaluate change over time and to determine when the inception cohort effect diminished. RESULTS: The CoULD cohort of 1,381 patients was found to have notable differences compared with a 1-year cross-sectional cohort from the U.S. Midwest and a Swedish birth registry. Each of these registries had differences from the CoULD population in prevalence for approximately 33% of the diagnosis categories. The CoULD registry identified and included more pathologies of late presentation and those that do not commonly require surgical care. Changes in relative frequencies of incident and prevalent conditions, the registry inclusion effect, occurred early and stabilized by the third year. CONCLUSIONS: The CoULD registry captures a different relative frequency of conditions than prior studies in similar populations. The findings highlight the CoULD registry may be a more accurate representation of clinical practice in tertiary referral centers; however, it is important to note that there was a registry inclusion effect identified. CLINICAL RELEVANCE: Inclusion criteria are an important consideration with any longitudinal data collection method and data should display stability prior to registry reporting.

Sprengel's deformity: an analysis of surgically and nonsurgically treated patients.

BACKGROUND: Sprengel's deformity is a congenital anomaly of the scapula and can be associated with reduced shoulder mobility and esthetic concerns. Controversies remain regarding its natural history, radiographic findings, and optimal treatment strategy. METHODS: A total of 74 Sprengel's shoulders in 71 patients presenting to a pediatric referral hospital were retrospectively reviewed including 24 surgically treated shoulders. Median age at initial presentation was 3.8 years. Median age at the final follow-up was 9.6 years. RESULTS: Twenty shoulders were analyzed for range of motion across time. The median composite abduction range was initially 105° and at the last time-point 98°, with a median loss of 15° over 5 years (P = .007). A total of 26% of the nonsurgical shoulders reported pain at the latest follow-up, compared with 1 surgical patient (4%) (P = .028). Older age was independently associated with pain (P < .001); this effect was only seen in nonsurgical patients. Radiographically, the glenoid inclination angle (GIA) independently correlated with the abduction range (P = .001). Surgically treated shoulders underwent a modified Woodward procedure at a median 4.8 years of age. At a median follow-up of 41 months, the abduction range improved in the surgical group from 90° preoperatively to 110° postoperatively, with a median gain of 40° (P < .001). The median GIA changed from -2° to 4° with a median gain of 9° (P = .004). CONCLUSIONS: The natural history of untreated Sprengel's deformity may be one of gradual decline in the abduction range, with a proportion of patients developing pain in adolescence. The GIA correlates with the shoulder abduction range. Surgery with a modified Woodward procedure may alter the natural history of the condition by improving motion and reducing risk of pain later in life.

Surgical Reconstruction of Missed Monteggia Lesions in Children.

BACKGROUND: Chronic Monteggia lesions in children may cause pain, deformity, decreased range of motion, and neurological symptoms. Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in efforts to maximize long-term upper limb function. The purpose of this investigation was to assess the clinical and radiographic results of a modified surgical technique for missed Monteggia fracture-dislocations. METHODS: A retrospective evaluation of 52 patients who underwent surgical reconstruction of missed Monteggia fracture-dislocations at a tertiary pediatric hospital was performed. The median patient age at the time of surgery was 6.8 years, and the median time from injury to surgery was 12.9 weeks. Electronic medical records, including clinic notes, radiographic images, and operative reports, were reviewed for study analysis. Median clinical and radiographic follow-up was 19.1 months. RESULTS: The median elbow range of motion improved from 108 degrees of flexion and 5 degrees short of full extension preoperatively to 140 degrees of flexion (P<0.001) and full extension (P=0.10) postoperatively. Forearm range of motion also improved from a median of 80 degrees of pronation and 58 degrees of supination preoperatively to 80 degrees of pronation (P=0.54) and 80 degrees of supination (P<0.001) postoperatively. Congruent radiocapitellar alignment was maintained in 39 patients (75%). Nine patients (17%) had redislocation of the radiocapitellar joint, and 4 patients (8%) had radiographic resubluxation. Six of the 9 patients who experienced redislocation underwent early revision and achieved uncomplicated longer term results. Patients who received repair of the native annular ligament were more likely to achieve lasting radiocapitellar joint stability (P=0.03) when compared with patients who received annular ligament reconstruction or if the annular ligament was not addressed. CONCLUSION: Meaningful improvements in elbow motion and radiocapitellar stability can be safely achieved in the majority of children following surgical reconstruction of missed Monteggia lesions. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Single-Bone Forearm as a Salvage Procedure in Recalcitrant Pediatric Forearm Pathologies.

PURPOSE: To report on the outcome of single-bone forearm reconstruction (SBFR) as a salvage procedure in pediatric forearm pathologies. METHODS: Twenty-eight forearms in 27 patients (median age, 9.6 years; range, 3.4-29.7 years) treated with SBFR at a pediatric referral center were included in the study. Records and radiographs were retrospectively analyzed. Median follow-up was 84 months (range, 24-261 months). The most common underlying condition was multiple hereditary exostoses (MHEs) (17 of 28), followed by brachial plexus birth injury (5 of 28), Ollier disease (2 of 28), congenital radial head dislocation (2 of 28), and others (2 of 28). RESULTS: By 4 months (range, 2-10 months) after surgery, 21 of 28 forearms had united. Median resting postoperative forearm rotation was 10° pronation (range, neutral to 25° pronation). Before surgery, pain was present in 23 of 28 forearms. At the latest follow-up, pain was present in 5 of 28 forearms. In three of the 5 forearms with residual pain, this was attributed to ulnohumeral degenerative changes that existed prior to SBFR. Following SBFR, elbow flexion-extension range was maintained. In the subgroup with MHEs, radial articular angle was maintained (median, 37°-30°) and carpal slip percentage improved significantly (median, 40%-12%). Complications occurred in 8 forearms: 3 cases of nonunion in older patients (age, 30, 20, and 14 years), 2 cases of traumatic juxtaimplant fractures following successful union, 1 case of infection, 1 case of compartment syndrome, and 1 case of persistent radiocapitellar impingement. All complications were successfully treated. When stratified by age, none of the patients in the younger group (16 forearms, age < 12 years) had nonunions or pain at latest follow-up. CONCLUSIONS: The SBFR is an old, but generally reliable, option as a single-stage salvage procedure for a number of recalcitrant pediatric forearm pathologies. Success rate may be higher in younger patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury.

BACKGROUND: Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood. METHODS: We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time. RESULTS: The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001). CONCLUSIONS: All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Congenital Pseudarthrosis of the Fibula: Controlling Ankle Valgus in a Heterogenous Condition.

BACKGROUND: Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS: Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS: The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion. CONCLUSIONS: Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF. LEVEL OF EVIDENCE: Level IV-case series.

Convergent Validity of PODCI and PROMIS Domains in Congenital Upper Limb Anomalies.

PURPOSE: This study evaluates the perceived functional and psychosocial impact of upper limb congenital anomalies prior to surgical intervention, utilizing the Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measure Information System (PROMIS) domains. We hypothesized that scores will be in the normal range and that the 2 outcomes measures will have strong convergent validity. METHODS: A multicenter prospectively collected database of congenital upper limb patients, the CoULD (Congenital Upper Limb Differences) study group, was utilized. Demographic information was collected, and anomalies were classified by the Oberg-Manske-Tonkin (OMT) classification. Scores for PODCI subscales of Upper Extremity (UE) function, Pain/comfort, and Happiness and PROMIS domain of UE function, Pain, Depression, Anxiety, and Peer relations were collected. Ceiling and floor effects and convergent validity for PODCI and PROMIS domains were calculated. RESULTS: Three hundred fifty-nine patients, average age 10 years and 55% male, were included. Two hundred forty-one patients had a malformation of the entire limb and 231 had a hand plate malformation. Four patients had a deformation, 118 dysplasia, and 45 a syndrome. There was no difference between the PODCI and the PROMIS ceiling or floor effects for the UE domains. The ceiling effect for PROMIS Pain domain (46%) was similar to the floor effect of the PODCI Pain subscale and no difference was seen between the floor effect of PODCI Happiness and PROMIS Depression domains. Convergent validity was obtained for the UE and Pain domains, and also between PODCI Happiness and PROMIS Depression subscales. CONCLUSIONS: The PROMIS domains for UE function, Pain, and Depression are comparable with PODCI scores in congenital upper extremity anomalies. CLINICAL RELEVANCE: Given the large burden placed on patients with the lengthy PODCI questionnaire, consideration of replacing the PODCI with the more quickly obtained PROMIS scores may reduce patient burden and provide similar information in this population.

Congenital pseudarthrosis of the clavicle: surgical decision making and outcomes.

BACKGROUND: Congenital pseudarthrosis of the clavicle (CPC) is a rare entity in which the primary ossification center of the clavicle fails to coalesce. The natural history of CPC is unknown, and there is controversy regarding surgical vs. conservative treatment. METHODS: A retrospective review of 47 pediatric patients treated for CPC was performed. The Quick Disabilities of the Arm and Shoulder (QuickDASH) survey and the Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity domain were used to assess overall patient satisfaction, function, and quality of life after treatment. RESULTS: Twenty-four of 47 (51%) patients underwent surgical treatment. Of these, 9 patients (38%, 9/24) underwent surgery at <18 months of age using suture fixation alone, whereas the older 15 surgical patients (15/24, 62%) were treated with plate fixation. The younger surgical cohort had a nonunion rate of 43% (3/7) compared with 13% (2/15) in the older cohort. All surgical patients had resolution of preoperative symptoms. Eleven (11/24, 46%) surgical subjects responded to the follow-up survey. Upper extremity function normalized according to the QuickDASH survey (score of 0 for all subjects). The median PROMIS upper extremity domain score was 55, which was also in the normal range. CONCLUSIONS: This series of CPC patients improves our understanding of treatment options and outcomes of surgical treatment. All surgical patients had resolution of preoperative symptoms. Patients treated surgically with stable fixation at an older age had higher rates of union than those treated in infancy with suture fixation. Patient-reported outcomes were favorable overall.