Ultrasonography of the pediatric elbow.

Ultrasound of the elbow can be incorporated into routine pediatric practice in the radiology department, emergency department, orthopedic clinic, and interventional suite. Ultrasound is complementary to radiography and magnetic resonance imaging for the evaluation of elbow pain in athletes with overhead activities or valgus stress, focusing on the ulnar collateral ligament medially and capitellum laterally. As a primary imaging modality, ultrasound can be used for a variety of indications including inflammatory arthritis, fracture diagnosis, and ulnar neuritis/subluxation. Ultrasound is also well-suited to guide diagnostic and therapeutic elbow joint interventions with precise localization of anatomic landmarks and needle placement. Here, we describe technical aspects of elbow ultrasound and illustrate its application in pediatric patients from infants to teen athletes.

Minimally Displaced Lateral Humeral Condyle Fractures: Optimizing Follow-up and Minimizing Cost.

BACKGROUND: Minimally displaced fractures of the lateral humeral condyle (LHC) may be treated nonoperatively in a long arm cast, but there is not a standardized evidence-based protocol. The aim of this study was to evaluate our nonoperatively treated LHC fractures, determine the risk of subsequent displacement, analyze our practice variability, and develop an evidence-based protocol to safely manage children with LHC fractures and to evaluate potential savings related to this analysis. METHODS: We retrospectively reviewed clinical and radiographic parameters of all patients with LHC fractures at our institution from 2009 to 2015. All patients treated nonoperatively initially were included. We recorded demographic data and calculated the number of visits, casts applied, and radiographs within the first 4 weeks. We also analyzed practice variation among 27 treating providers. The number of children with subsequent displacement needing operative fixation was determined. We also looked at the average duration for each follow-up visit and the charges/costs associated with casting and radiographs. RESULTS: There were 271 children with LHC fractures treated nonoperatively. Twenty-one were excluded because of the lack of adequate radiographs. There were 157 boys and 93 girls (average age 6.7 y). According to the Jakob classification, fracture types were as follows: 1 (230), 2 (20), and 3 (0). Within the first 4 weeks, the average number of visits was 2.6 (range: 1 to 5), average number of casts was 2.4 (range: 1 to 4), and the average number of radiographs was 9.4 (range: 2 to 31). Only 3 patients with LHC fracture type Jakob 1 were taken to the operating room post injury (9, 12, and 15 d, respectively) for subsequent displacement. CONCLUSION: Displacement in appropriately selected LHC fractures treated nonoperatively was rare (3/250, 1.2%) in this cohort, and the data question the need for multiple visits and radiographs in the first 4 weeks. Optimal follow-up (proposed follow-up at 10 to 15 d after injury and then 4 to 6 wk with radiographs, including an internal oblique view) would be safe, minimize waste, and result in better value-based care. LEVEL OF EVIDENCE: Level IV.

Male Versus Female Authorship in Flagship Pediatric Orthopaedic Journals From 2002 to 2021.

BACKGROUND: The evolution of female authorship in orthopaedic journals is reportedly rising, however, trends in pediatric orthopaedic publications have not been specifically studied, despite a higher proportion of female pediatric orthopaedic surgeons compared with orthopaedics at large. This study aimed to investigate trends in female first and senior authorship in 3 flagship pediatric orthopaedic journals over the past 20 years. METHODS: All manuscripts from the "Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics Part B, and Journal of Children's Orthopaedics" from 2002 to 2021 were evaluated from Ovid MEDLINE, and the data were extracted. We utilized the sex "Application Program Interface" algorithm to determine the sex of the first and senior authors. χ 2 tests were used to analyze the demographics of the first and senior author cohorts. Fisher exact test was used to assess the trends in male and female authorship, controlling for year and journal. RESULTS: Of a total, 5499 individual first authors and 5794 senior authors were identified. Sex was determined for 83.5% of the authors. Female first authorship increased significantly from 2002 to 2021 (8.8% to 22.4%, P < 0.001), with women being more likely to publish as first authors in more recent years in each journal ( P < 0.001). Female senior authorship did not increase significantly over the same time period (10.8% to 12.8%, P = 0.238). There was significantly more male than female first and senior authors for all journals ( P <0.001 for both first and senior authors). CONCLUSIONS: While female first authorship in prominent pediatric orthopaedic journals has increased significantly from 2002 to 2021, senior authorship has remained stagnant. In addition, female pediatric orthopaedic surgeons publish at rates lower than their prevalence in the field. This study serves as a benchmark for future studies looking at sex and authorship in hopes of better understanding the underlying complex issues. LEVEL OF EVIDENCE: Level III.

The Fate of the Bent Rod in Children With Osteogenesis Imperfecta.

BACKGROUND: Osteogenesis imperfecta (OI) is a genetic disorder characterized by brittle bones and long bone deformity. Realignment and intramedullary rodding with telescopic rods are indicated for progressive deformity and can help prevent fractures. Rod bending is a reported complication of telescopic rods and a common indication for revision; however, the fate of bent lower extremity telescopic rods in the setting of OI has not been reported. METHODS: Patients with OI at a single institution who underwent lower extremity telescopic rod placement with at least 1-year follow-up were identified. Bent rods were identified, and for these bone segments, we collected the location and angle of bend, subsequent telescoping, refracture, increasing angulation of bend, and date of revision. RESULTS: One hundred sixty-eight telescopic rods in 43 patients were identified. Forty-six rods (27.4%) bent during follow-up, with an average angulation of 7.3 (range: 1 to 24) degrees. In patients with severe OI, 15.7% of rods bent compared with 35.7% in nonsevere OI ( P =0.003). The proportion of bent rods was different between independent and nonindependent ambulators (34.1% and 20.5%; P =0.035). Twenty-seven bent rods (58.7%) were revised, with 12 rods (26.0%) revised early (within 90 d). The angulation of rods that were revised early was significantly higher than rods not (14.6 and 4.3 degrees, P <0.001). Of the 34 bent rods not revised early, the average time to revision or final follow-up was 29.1 months. Twenty-five rods (73.5%) continued to telescope, 14 (41.2%) increased in angulation (average 3.2 degrees), and 10 bones (29.4%) refractured. None of the refractures required immediate rod revision. Two bones had multiple refractures. CONCLUSIONS: Bending is a common complication of telescopic rods in the lower extremities of patients with OI. It is more common in independent ambulators and patients with nonsevere OI, possibly because of the increased demand placed on the rods. Rods with a small bend and maintained fixation can telescope and need not be an indication for immediate revision. LEVEL OF EVIDENCE: Level III-Retrospective review.

Anterior Vertebral Body Tethering: A Review of the Available Evidence.

Idiopathic scoliosis is a complex three-dimensional deformity of the spine with anterior overgrowth (hypokyphosis), coronal curvature, and axial rotation. Scoliosis treatment in the skeletally immature spine is therapeutically challenging because of growth and was commonly limited to observation, bracing treatment, or fusion. Fusion accomplishes powerful deformity correction at the expense of future growth and mobility of the involved segments, increasing the risk of adjacent segment degeneration and intervertebral disk disease later in life. Anterior vertebral body tethering is a motion-preserving technique that exploits the Hueter-Volkmann principle by applying compression at the anterior and convex aspects of the curve to stimulate differential vertebral growth for gradual deformity reduction without fusion. The appropriate timing, curve magnitude, tensioning, growth prediction, indications, and limitations of tethering are being refined as this technique becomes more prevalent. Early outcome studies show that growth modulation with vertebral body tethering is safe, can achieve good results, and preserve motion in select patients.

Preoperative Biopsychosocial Assessment and Length of Stay in Orthopaedic Surgery Admissions of Youth with Cerebral Palsy.

Caregivers of children with cerebral palsy (CP) experience stress surrounding orthopaedic surgery related to their child's pain and recovery needs. Social determinants of health can affect the severity of this stress and hinder health care delivery. A preoperative biopsychosocial assessment (BPSA) can identify risk factors and assist in alleviating psychosocial risk. This study examined the relationship between the completion of a BPSA, hospital length of stay (LOS), and 30-day readmission rates for children with CP who underwent hip reconstruction (HR) or posterior spinal fusion (PSF). Outcomes were compared with a matched group who did not have a preoperative BPSA. The BPSA involved meeting with a social worker to discuss support systems, financial needs, transportation, equipment, housing, and other services. A total of 92 children (28 HR pairs, 18 PSF pairs) were identified. Wilcoxon analysis was statistically significant (p = 0.000228) for shorter LOS in children who underwent PSF with preoperative BPSA (median = 7.0 days) vs. without (median = 12.5 days). Multivariate analysis showed that a BPSA, a lower Gross Motor Function Classification System level, and fewer comorbidities were associated with a shorter LOS after both PSF and HR (p < 0.05). Identifying and addressing the psychosocial needs of patients and caregivers prior to surgery can lead to more timely discharge postoperatively.

Treatment of a Lisfranc Injury in a 7-Year-Old Boy: Case Report and Surgical Technique.

CASE: This is a case of a 7-year-old boy with a Lisfranc injury identified on weight-bearing films who was treated successfully with closed reduction with a clamp and smooth pin fixation. This patient returned to sports without pain or radiographic signs of arthritis at 1 year. CONCLUSION: Lisfranc fractures and ligamentous injuries are rare and can occur in skeletally immature children. They have high potential for long-term disability if not properly diagnosed and treated. Although there is no consensus on optimal management of pediatric Lisfranc injuries, restoration of an anatomic Lisfranc joint with smooth pins and immobilization for 6 weeks is a viable treatment option.

Radial Head Incarceration After Closed Reduction of a Pediatric Elbow Dislocation With a Radial Neck Fracture: A Case Report.

CASE: A 10-year-old girl sustained a radial neck fracture with a posterior elbow dislocation. She was treated with closed reduction of the elbow with subsequent intra-articular displacement of the radial head, which necessitated open reduction and pinning of the radial neck fracture. CONCLUSION: Displacement of the radial neck fracture from impingement of the capitellum on the anterior radial head during closed reduction of the elbow dislocation is a rare injury pattern. It is important to examine the radial neck in high-energy posterior elbow dislocations before attempted reduction. We present a case with imaging depicting the injury mechanism and successful management with subsequent open reduction and fixation of the radial neck fracture.