Journal of Pediatric Orthopaedics最新文献

Background: Distal radius fractures involving the physis are among the most common upper extremity injuries in children and adolescents. Unlike transitional fractures of the distal tibia, known as Tillaux and triplane fractures, transitional fractures of the distal radius have not been well characterized. This study aims to evaluate Salter-Harris III and IV fractures of the distal radius in the pediatric transitional age population to determine if a characteristic fracture pattern exists analogous to the distal tibia. We hypothesized that pediatric transitional fractures of the distal radius would follow a pattern that would ultimately dictate treatment and predict outcomes.

Methods: A retrospective chart review of pediatric patients with transitional fractures of the distal radius at a single institution was performed. Salter-Harris III and IV fractures of the distal radius with CT imaging were included. Two independent reviewers determined the metaphyseal fracture plane and the major intra-articular epiphyseal fracture fragments. Descriptive statistical analysis was performed.

Results: Thirty patients who met inclusion criteria made the study cohort. There were 5 Salter-Harris III fractures and 25 Salter-Harris IV fractures. Mean age at the time of injury was 15±1.5 years. The metaphyseal fracture demonstrated a coronal fracture plane in all cases, and 20% had a sagittal plane component. The major epiphyseal fracture fragments were identified as dorsal ulnar corner in 70%, radial column in 43%, volar rim in 30%, and dorsal wall in 17%. Patients were treated with open reduction and internal fixation (N=12, 40%), closed reduction and percutaneous pinning (N=4, 13%), or cast immobilization (N=14, 47%). Most patients (N=24, 80%) did not demonstrate a growth disturbance after treatment. Angular deformity, however, was significantly higher in patients with a primary dorsal ulnar corner epiphyseal fragment (N=4, 19% vs. N=0%, P =0.03).

Conclusion: Transitional fractures of the distal radius occurred on average at age 15. The injuries demonstrated a consistent pattern, with a coronal fracture plane in the metaphysis and a dorsal ulnar corner fragment in most epiphyses. The dorsal physis may be the strongest portion of the distal radius at the time of injury, though mechanism of injury may impact patterns as well.

Level of evidence: Level III.

Background: Trauma centers may utilize fracture clinics primarily staffed by advanced practice clinicians (APC) for management of basic fractures that typically require few visits. It is unclear if provider continuity is important in these brief health care encounters. The purpose of this study was to determine the association between continuity of care and patient satisfaction scores in APC-run urgent/fracture clinics.

Methods: This was a retrospective IRB-approved study at a pediatric tertiary-care Level-1 trauma hospital. We reviewed prospectively collected Press Ganey data from 2021 to 2023 for acute injury/fracture patients seen in a pediatric orthopaedic fracture clinic, which is APC-staffed and physician-supervised. Demographic and clinical data were collected along with the results of 4 Press Ganey patient satisfaction survey items ( recommend provider , teamwork , recommend practice , overall rating ). Univariate and multivariable models were conducted to determine independent predictors of patient satisfaction, including the effect of continuity of care.

Results: A total of 230 follow-up encounters were reviewed. Median age was 11 years (range, 0 to 17). The majority of patients were male (59%), White (75%), with a very high child opportunity index (72%). Patients who saw the same provider at follow-up had a higher proportion of top-box ratings compared with those who saw a different provider for 3 of 4 outcomes: 88% versus 76% for staff teamwork ( P =0.04), 94% versus 78% for recommend practice ( P =0.003), and 93% versus 76% for overall rating of care ( P =0.003). After adjusting for consistency of care, location, age, sex , child opportunity index, injury region, and geographical distance from clinic, the odds of receiving a top-box rating for recommend practice were 4.7 times higher ( P =0.004) and 3.8 times higher for overall rating ( P =0.002) for patients with continuity of care-provider.

Conclusions: Continuity of APC care-provider has a positive impact on patient satisfaction in a pediatric fracture clinic, as patients who saw the same provider in successive follow-up visits. Demographic, geographic, and clinical factors had comparatively little effect on patient satisfaction. The provider remains a fundamental factor in patient experience.

Level of evidence: Level II.

Background/objectives: Lateral ankle injuries are common in pediatric populations. Avulsion fractures are a distinct injury involving bony disruption and may be underrecognized given their radiographically occult nature in skeletally immature patients. This study aims to compare the frequency, clinical presentation, and patient-reported outcomes (PROs) of lateral ankle avulsion fractures versus non-avulsion injuries in pediatric patients, with a focus on age-related differences.

Methods: Prospective cohort observational study conducted at a tertiary pediatric orthopedic/sports medicine practice. Patients aged 5 to 12 with a first lifetime lateral ankle injury within 30 days of the injury were consecutively enrolled, receiving clinical radiographs and research-based lateral ankle ultrasounds. Patients were classified into avulsion and non-avulsion groups based upon ultrasound findings, and additional comparisons were done between younger (age 5 to 10) and older (age 11 to 12) groups.

Results: Among 132 patients (mean age 9.95 (95% CI: 9.54-10.36), 56% younger group, 65% female), 44 avulsion fractures (33%) were identified. Avulsion fractures were significantly more common in the younger group (47%) than in the older group (16%) ( P <0.001). Swelling and bruising were more frequent in avulsion fractures ( P <0.001). Despite differences in injury type, initial presentation PROs did not differ.

Conclusions: Avulsion fractures account for one-third of pediatric lateral ankle injuries and are more frequent in younger children than older children, likely due to greater skeletal immaturity. Swelling and bruising may aid in accurate diagnosis. Longitudinal studies are needed to determine if these fractures lead to subfibular ossicles, which are associated with chronic pain and instability.

Level of evidence: Level II.

Background: Patients with congenital scoliosis may develop a large, unbalancing "compensatory" curve as they grow, which can be severely deforming. It is important to identify characteristics of patients who develop a "dominant" compensatory curve (one that is larger than the congenital curve) to help identify patients who may benefit from prophylactic treatment.

Methods: By searching the Pediatric Spine Study Group database, we identified 307 patients 18 years and above with congenital scoliosis who had preoperative radiographs taken during at least 2 years of natural growth (period of no bracing or surgery). Seventeen patients (6%) had a dominant compensatory curve, and 290 had no compensatory curve or one that was smaller than the congenital curve. Of those 290 patients, 100 were randomly selected to serve as a control group, which we refer to as the "nondominant curve group." We analyzed the type of congenital anomaly and its vertebral level, as well as the major curve angles of the congenital and compensatory curves at initial and latest follow-up. We compared vertebral level and type of anomaly between groups using χ 2 tests. Alpha = 0.05.

Results: The congenital anomaly was at L4 or more caudal in 18% of patients in the dominant curve group and no patients in the nondominant curve group ( P <0.001). Similarly, the congenital anomaly was at T6 or more cranial in 59% of patients in the dominant curve group and 28% of patients in the nondominant curve group ( P <0.001). At the latest follow-up, the dominant curve group had a mean (and SD) congenital curve of 55±19 degrees and a compensatory curve of 73±24 degrees. The frequencies of wedge, hemivertebrae, and bar vertebral anomalies did not differ between groups.

Conclusions: In pediatric patients with congenital scoliosis, a dominant compensatory curve was associated with vertebral anomaly at L4 or caudal, or T6 or cranial. These findings can help clinicians prioritize prophylactic treatment for patients who may be at high risk for developing a dominant compensatory curve.

Level of evidence: Level III.

Introduction: Tibial tubercle fractures' (TTF) preferred repair technique with headed cannulated screws is associated with reoperation rates of 50% to 60% for removal of hardware (ROH). A newer screw design is headless compression screws (HCS).

Aim: This project hypothesized that utilization of lower-profile HCS would reduce rates of pain and reoperation rates for removal of hardware in pediatric TTF, while maintaining comparable fracture healing and functional outcomes.

Methods: An institutional review board approved, multicenter, retrospective, case-control study with data collected for all surgeries between 2014 and 2024. A priori power analysis was performed, targeting significant reduction in ROH rates.

Results: A total of 283 TTF were identified; 148 met inclusion criteria, with most excluded for alternative fractures, surgical treatment, or insufficient follow-up. 121 were treated with cannulated, headed screws and 27 with HCS. Patients were 93.2% male, most commonly black (55%), average age 14.5 years, weight 85th percentile, height 71st percentile, and body mass index of 79th percentile. Injuries were most often during basketball (47%). All fracture patterns from Ogden 1A to 4B were represented, and the most common pattern was 3A (31%); no patterns were excluded. The typical repair consisted of 2 to 3 screws of 4.5 to 5.5 mm diameter, and 28% with supplemental fixation. The only difference between the headed and HCS groups was washer usage (50% vs. 0%, P <0.001). Given the demographic difference in washer use, subgroup analysis was performed to separate the washer and washer-less headed cannulated screw constructs. There were no differences in postoperative management, including immobilization (71% knee immobilizer), days to motion (29), and days to weight bearing (35). Total follow-up period was similar (266 d). There were no differences in hardware failure. Neither group experienced nonunion. Compared with headed screws with washers, the HCS group had significantly less pain (38% vs. 11%, P =0.005), relatively fewer wound complications and infections (both 2.5% vs. 0%, P =0.12), and significantly lower rates of ROH (40% vs. 7.4%, P <0.001).

Conclusion: Compared with the preferred standard TTF fixation of headed cannulated screws, patients who received HCS had equivalent surgical, healing, and management outcomes, with relatively lower rates of wound complications and infections, significantly less pain, and significantly fewer returns to the operating room for ROH.

Evidence: Level III-multicenter case-control.

Background: Lower extremity rotational abnormalities can cause difficulty with ambulation, patellofemoral pain and instability, hip and ankle pain, as well as differences in self-image in children and adolescents. Rotational osteotomies of the femur to correct these torsional differences have been shown to improve function, pain, and self-image. There are no studies to date evaluating risk factors for nonunion after femoral rotational osteotomies in children and adolescents.

Methods: Patients 10 to 18 years old treated with femoral rotational osteotomy fixed with intramedullary nailing for idiopathic anteversion and retroversion over a 15-year period were included. Charts and radiographs were reviewed for patient characteristics, laterality, concomitant tibia osteotomy, nail material, interlocking screw construct, and radiographic measurements, including osteotomy location and canal fit. Patients with nonunion were compared with those who fully healed.

Results: In this study of 203 femoral rotational osteotomies in 118 adolescent patients, the total incidence of nonunion was 10/203 for a rate of 4.9%. Overall complication rate was 6.9%. Univariate analysis of patient factors revealed that patients who were older, had a higher weight, and higher BMI were at higher risk of nonunion. The use of static interlocking screws and a lower canal fit ratio were also associated significantly with nonunion. Multivariate stepwise linear regression found relative canal fit ( P = 0.003) and interlock configuration ( P = 0.003) to be significant, and causal modeling identified significant factors related to nonunion as older age, static interlock type, and lower canal fit.

Conclusions: Nonunion after femoral osteotomy is associated with higher age, weight, and BMI as well as use of static interlocking screws and lower canal fit ratio. Surgeons can use this information to risk stratify and counsel patients undergoing this procedure. Surgical techniques to minimize the chance of nonunion include use of dynamic interlocking screws and maximizing the canal fit ratio.

Level of evidence: Therapeutic level III-case-control study.

Introduction: Tibial shaft fractures are common fractures in children. The optimal management should be selected based on the fracture type, the child's weight, and the presence of open growth plates. When surgical treatment is indicated, elastic-stable intramedullary nailing (ESIN) is considered the generally preferred method in children with open physes. However, in some cases, alternative treatment may be required.

Aim: The aim of this study was to compare the outcomes of tibial shaft fractures in children treated with ESIN versus minimally invasive plate osteosynthesis (MIPO).

Methods: Fifty-nine children were treated for unstable tibial shaft fractures between 2018 and 2023 (27 with MIPO and 32 with ESIN). Patients' demographics, fracture type, surgery duration, and complications were recorded based on medical records. Bone healing, tibial axis, and implant position were assessed on follow-up radiographs. Functional outcomes were evaluated using the EFAS Questionnaire at 3.7±1.8 years (range: 1.0 to 6.8) after surgery.

Results: Bone union was achieved in all patients. The total complication rate was 7.4% in the MIPO group and 15.6% in the ESIN group ( P =0.4365). No reoperations were required in the MIPO group, while 12.5% of patients in the ESIN group required reoperation ( P =0.1176). A plaster cast was applied in 46.9% of ESIN patients and in none of the MIPO patients. The surgery duration was significantly longer in the MIPO group (79.0 vs. 41.8 min in the ESIN group; P =0.0001). There was no significant difference in the final tibial axis at the final follow-up (2 ESIN patients underwent reoperation for axis correction). There was no significant difference in EFAS Questionnaire scores: 38.1±2.1 in the MIPO group versus 36.5±3.9 in the ESIN group ( P =0.1235).

Conclusions: Minimally invasive plate osteosynthesis is a promising alternative to elastic-stable intramedullary nails in the most severe, unstable tibial shaft fractures. Plating provides better stabilization without the need for a plaster cast; however, surgery time is longer.

Level of evidence: Level III.

Background: After reduction of developmental hip dislocations, residual dysplasia is common with rates of secondary reconstructive surgery with pelvic osteotomy ranging from 19% to 60%. The determination and timing of when to proceed with surgery is difficult as acetabular remodeling occurs gradually over the first few years after reduction. The purpose of this study was to evaluate how age at secondary reconstructive surgery influences the clinical and radiographic outcomes after pelvic osteotomy for residual dysplasia.

Methods: After IRB approval, we retrospectively reviewed all isolated Salter or Pemberton pelvic osteotomies performed for residual dysplasia after an index closed or open reduction at a single institution between 1983 and 2020 with radiographic follow-up through skeletal maturity. Acetabular index (AI) and migration index (MI) were measured on preoperative, immediate postoperative, and 2-year follow-up radiographs. After triradiate cartilage closure, anterior-posterior pelvis radiographs were measured for lateral center-edge angle (LCEA), Tönnis angle, MI, and lateralization ratio (LR). Univariate and multivariate analysis were used to evaluate outcomes based on age at time of surgery.

Results: Ninety-two hips from 83 patients were included. 55 Salter (60%) and 37 Pemberton osteotomies (40%) were performed with mean age at surgery of 5.2±1.7 years. 46% (42/92) hips across both treatment groups had residual dysplasia (LCEA<25 deg.) at final follow-up (mean age 15±3.2 y). However, there was no significant difference in acetabular dysplasia at 2 years postop or after triradiate closure between those hips treated before or after 5 years of age (all P >0.05). Multivariate analysis revealed that only the immediate postoperative MI predicted the final follow-up LCEA ( P <0.01), although the rate of dysplasia was still 24% in the most covered hips (MI<10%).

Conclusions: Even after pelvic osteotomy for residual dysplasia, there are high rates of dysplasia at skeletal maturity. Only the femoral head coverage achieved, not the age at time of surgery, predicted dysplasia at skeletal maturity. These findings suggest that there is no opportunity cost to short-term continued observation while monitoring for acetabular remodeling.

Level of evidence: Level III.