Ultrasound Examination for Infants Born Breech by Elective Cesarean Section With a Normal Hip Exam for Instability.

INTRODUCTION: Because of the risk of developmental dysplasia of the hip in infants born breech-despite a normal physical exam-the American Academy of Pediatrics (AAP) guidelines recommend ultrasound (US) hip imaging at 6 weeks of age for breech females and optional imaging for breech males. The purpose of this study is to report US results and follow-up of infants born breech with a normal physical exam. METHODS: The electronic medical record for children born at 1 hospital from 2008 to 2011 was reviewed. Data were analyzed for sex, birth weight, breech position, birth order, ethnicity, US and x-ray results, follow-up, and cost. RESULTS: A total of 237 infants were born breech with a normal physical examination, all delivered by cesarean section. Of the infants, 55% were male and 45% female. About 151 breech infants (64%) with a normal Barlow and Ortolani exam had a precautionary hip US as recommended by the AAP performed at an average of 7 weeks of age. Eighty-six breech infants (35%) did not have an US and were followed clinically. Of the 151 infants that had an US, 140 (93%) were read as normal. None had a dislocated hip. Two patients had a normal physical exam but laxity on US. These 2 patients were the only infants treated in a Pavlik harness. A pediatric orthopaedic surgeon followed those with subtle US findings and no laxity until normal. CONCLUSIONS: The decision by the AAP to recommend US screening at 6 weeks of age for infants with a normal physical exam but breech position was based on an extensive literature review and expert opinion. Not all pediatricians are following the AAP guidelines. The decision to perform an US should be done on a case-by-case basis by the examining physician. A more practical, cost-effective strategy would be to skip the US if the physical exam is normal and simply obtain an AP pelvis x-ray at 4 months. LEVEL OF EVIDENCE: Level III-this is a case-control study investigating the outcomes of infants on data drawn from the electronic medical record.

A Radiation Safety Training Program Results in Reduced Radiation Exposure for Orthopaedic Residents Using the Mini C-arm.

BACKGROUND: Fluoroscopy during fracture reduction allows a physician to assess fractures and immediately treat a pediatric patient. However, concern regarding the effects of radiation exposure has led us to find ways to keep radiation exposures as low as reasonably achievable. One potentially simple way, which to our knowledge has not been explored, to decrease radiation exposure is through formal education before mini C-arm use. QUESTIONS/PURPOSES: We questioned whether a radiation safety educational program decreases radiation (1) time and (2) exposure among residents and patients. PATIENTS AND METHODS: This is a retrospective study in which second-year residents underwent a 3-hour educational program regarding mini C-arm use and radiation safety taught by our institution's health physics department. We evaluated the records of all patients who underwent a pediatric both-bone forearm or distal radius fracture reduction in the emergency department 3 months before the educational program or after the program. To be included in the study, records included simple both-bone forearm fractures, simple distal radius fractures, and patient age younger than 18 years, and could not include patients with multiple fractures in the same limb. This resulted in study groups of 53 and 45 patients' records in the groups before and after the educational session, respectively. Radiation emission from the mini C-arm between both groups were compared. RESULTS: Exposure time with the mini C-arm was longer in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 41.2, SD = 24.7, 95% CI, 23.14-59.26 vs mean = 28.9, SD = 14.4, 95% CI, 15.91-41.89, p = 0.066; patients with distal radius fractures: mean = 38.1, SD = 26.1, 95% CI, 25.1-51.1 vs mean = 26.7, SD = 15.8, 95% CI, 16.44-36.96, p = 0.042). Calculated radiation exposure with the mini C-arm was larger in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 90.9, SD = 60.9, 95% CI, 51.06-130.74 vs mean = 30.4, SD = 18.5, 95% CI, 16.73-44.07, p < 0.001; patients with distal radius fractures: mean = 83.1, SD = 58.9, 95% CI, 54.75-111.45 vs mean = 32.6, SD = 26.4, 95% CI, 20.07-45.13, p < 0.001). CONCLUSIONS: A radiation-safety program resulted in decreased radiation exposure to residents and patients, and in decreased mini C-arm exposure time during pediatric fracture reductions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Measurement of Radiation Exposure When Using the Mini C-Arm to Reduce Pediatric Upper Extremity Fractures.

BACKGROUND: Previous literature has underreported radiation exposure with the use of mini C-arm during pediatric forearm fracture reductions. The purpose of this study is to report an accurate amount of radiation exposure during fracture reductions using a mini C-arm that records the amount of kilovolts, milliamps, and the number of seconds of foot pedal use. METHODS: Eighty-six consecutive pediatric patients undergoing upper extremity fracture reduction in the emergency department were studied. The orthopaedic resident, either a PGY2 or PGY3, performed a manipulative reduction and casting of the fracture with use of the mini C-arm. Postreduction, in cast, anteroposterior and lateral images from the mini C-arm were saved to the computerized radiology system. The mini C-arm recorded the amount of kilovolts, milliamps, and the number of seconds that the foot pedal was used for each reduction. A radiology physicist (S.K.) calculated the amount of millirem (mR) exposure for each reduction from these data. RESULTS: The resident using the mini C-arm and the fracture pattern affected the amount of radiation exposure. The average mini C-arm mR exposure for distal radius fractures was 63 mR; forearm 109 mR; elbow 53 mR; and hand 69 mR. For comparison, conventional anteroposterior/lateral forearm radiographs emit an average of 20 mR. Less-experienced PGY2 residents had a higher mR exposure per reduction compared with PGY3 residents. CONCLUSIONS: Radiation exposure when using the mini C-arm for reduction of pediatric fractures has been underestimated in previous literature. Radiation from the mini C-arm exceeded that from conventional radiographs in most cases. We recommend that residents receive training about the use of the mini C-arm before its utilization as an aid to reduce pediatric fractures in the emergency department.

Reliability of Tanner staging performed by orthopedic sports medicine surgeons.

PURPOSE: The treatment of anterior cruciate ligament (ACL) tears in children is controversial because of the potential injury to the growth plate resulting from traditional transphyseal surgery. Some authors recommend Tanner staging as a method to determine the patient's maturity to decide between physeal-sparing or transphyseal surgery. This study examines the accuracy and interobserver and intraobserver reliabilities of Tanner staging performed by orthopedic surgeons. METHODS: Twenty-eight photographs representing Tanner stages 1-5 were obtained from a pediatric endocrinologist. Four sports medicine orthopedic surgeons received a tutorial on Tanner staging and independently graded the photographs twice, with a 1-month interval between grading exams. The endocrinologist's grade was considered correct. Intraobserver and interobserver reliabilities were determined. RESULTS: The overall average correct scores were as follows: 53% correct Tanner stages on exam 1 and 59% correct on exam 2. The average results for specific Tanner stages were as follows: Tanner stage 1 = 62% correct on exam 1, 83% on exam 2; Tanner stage 2 = 60%/65%; Tanner stage 3 = 60%/46%; Tanner stage 4 = 45%/55%; and Tanner stage 5 = 50%/45%. Per examiner, correct grading was as follows: examiner 1 = 39% on exam 1 and 35% on exam 2; examiner 2 = 67%/82%; examiner 3 = 50%/42%; and examiner 4 = 67%/75%. When comparing the grading between exams 1 and 2, examiner 1 changed five answers from correct to incorrect; four answers from incorrect to correct; and two answers from incorrect to a different incorrect choice; examiner 2, three/seven/zero; examiner 3, six/four/one; and examiner 4, two/four/zero. CONCLUSIONS: Preoperative Tanner staging performed by orthopedic surgeons is unreliable with large intraobserver and interobserver variabilities. Therefore, relying on Tanner staging as a method to guide decision making for surgery in skeletally immature patients with ACL tears may lead to inadvertent growth plate injury.

Monocilia in the embryonic mouse heart suggest a direct role for cilia in cardiac morphogenesis.

Primary cilia are required for signaling, chemosensing and mechanosensing in many fluid-filled organs, thus cilia could also have a direct role in heart development. They are essential to the development of cardiac left-right (LR) asymmetry by means of their function at the embryonic organizer (node). We show that cilia are found in the mouse embryo heart at embryonic day (e) 9.5-e12.5. We demonstrate abnormal development of the endocardial cushions (ECCs) and compact myocardium (CM) in e9.5 mouse embryos with absent cilia. In contrast, hearts from embryos with abnormal LR development due to paralyzed, but structurally normal, node cilia show less severe ECC defects and normal CM. These observations suggest that a subset of cilia called cardiac cilia are required in cardiac development independently from their function in LR development. One possible function of cardiac cilia is as mechanosensors, integrating flow, cardiac function, and morphogenesis.