Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients.

INTRODUCTION: Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution. METHODS: We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships. RESULTS: Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10. CONCLUSIONS: We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Patient and Parent Satisfaction With Sling Use After Pediatric Upper Extremity Fractures: A Randomized Controlled Trial of a Customized Cast-Sling Versus Standard Cast and Sling.

BACKGROUND: Long arm cast immobilization after operative and nonoperative treatment of pediatric upper extremity fractures is common. The use of a sling to aid in carrying the casted extremity as well as provide further immobilization is also common practice. Off-the-shelf slings vary in quality and fit, can be confusing for parents/patients to apply, and lead to frustration and dissatisfaction with its use. The purpose of this investigation was to compare patient/parent centered outcomes after the use of a customized sling compared with a standard sling by utilizing a prospective, randomized-controlled trial. We hypothesized that patients and their parents would find the "Providence" Pedi Cast-Sling (PPCS) to be more convenient and be more satisfied with its use compare with a standard sling. METHODS: Eligible subjects included patients 0 to 18 years old, evaluated at an urban, tertiary care pediatric emergency department (ED), who sustained an upper extremity fracture that required placement of a long-arm cast. Exclusion criteria were: open fractures; fractures at multiple levels; fractures requiring urgent/emergent surgery; admitted patients; bivalved casts. Patients were randomized to receive a standard sling or a PPCS. Questionnaires assessing patient/parent satisfaction, preferences, sling-use, and pain level were collected at patients' first follow-up visit. RESULTS: A total of 100 patients were randomized with 71 questionnaires available for analysis (39 standard sling vs. 32 PPCS). There were statistically significant differences for satisfaction scores for all related questions between patients who received a PPCS compared with a standard sling. Patients and their parents were more likely to choose the PPCS (P=0.001), were more satisfied with the PPCS (P<0.006), and reported the PPCS to be more convenient than a standard sling (P<0.001). Patients who received a PPCS wore the sling for a greater number of hours during the day (10.3±7.1 h) compared with those who received a standard sling (5.9±5.0 h) (P=0.004). CONCLUSIONS: The "Providence" Pedi Cast-Sling is a superior alternative to an off-the-shelf sling when used after the application of a long-arm cast providing greater convenience, compliance, and satisfaction to both patients and families. LEVEL OF EVIDENCE: Level I-Prospective randomized-controlled trial.