Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-716
Austin Broussard, J. Sanders, William K. Accousti, R. C. Clement
Intraarticular distal humerus fractures occur in adolescents and represent a unique morphology that is amenable to different surgical techniques than distal humerus fractures in adults or younger children, especially when one column remains intact. Despite articular involvement, a minimally invasive approach utilizing the intact periosteum and opposing intact column of bone can often achieve successful reduction and fixation. Here, we present an operative technique for these fractures along with four cases successfully treated with percutaneous lag screws.
{"title":"Minimally Invasive Methods for Adolescent Intraarticular Distal Humerus Fractures with an Intact Column","authors":"Austin Broussard, J. Sanders, William K. Accousti, R. C. Clement","doi":"10.55275/jposna-2023-716","DOIUrl":"https://doi.org/10.55275/jposna-2023-716","url":null,"abstract":"Intraarticular distal humerus fractures occur in adolescents and represent a unique morphology that is amenable to different surgical techniques than distal humerus fractures in adults or younger children, especially when one column remains intact. Despite articular involvement, a minimally invasive approach utilizing the intact periosteum and opposing intact column of bone can often achieve successful reduction and fixation. Here, we present an operative technique for these fractures along with four cases successfully treated with percutaneous lag screws.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"43 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128801385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-700
D. Bae
Z-plasty refers to a local soft-tissue transposition using interdigitating triangular flaps and is a simple but powerful surgical technique to transpose skin, lengthen scars, and shift topography. There are a host of applications of this technique within pediatric orthopaedics, given the spectrum of traumatic, post-traumatic, and congenital differences affecting the growing child. The purpose of this Master’s Surgical Technique supplement is to describe the principles and common applications of z-plasties in pediatric orthopaedic surgery.
{"title":"Z-plasties for the Pediatric Orthopaedic Surgeon","authors":"D. Bae","doi":"10.55275/jposna-2023-700","DOIUrl":"https://doi.org/10.55275/jposna-2023-700","url":null,"abstract":"Z-plasty refers to a local soft-tissue transposition using interdigitating triangular flaps and is a simple but powerful surgical technique to transpose skin, lengthen scars, and shift topography. There are a host of applications of this technique within pediatric orthopaedics, given the spectrum of traumatic, post-traumatic, and congenital differences affecting the growing child. The purpose of this Master’s Surgical Technique supplement is to describe the principles and common applications of z-plasties in pediatric orthopaedic surgery.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"70 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133054933","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-696
Garrett E. Rupp, Joanna L. Langner, Claire E. Manhard, Amy W. Bryl, V. Upasani
Background: Opioid abuse and overdose are in epidemic range in the United States and medical prescriptions, including those for postoperative analgesia, are a large contributing source to this misuse. Our quality improvement initiative aimed to reduce the opioid prescribing of pediatric orthopaedic surgeons in the postoperative setting. The aim was to decrease the percentage of children with surgically treated supracondylar humerus (SCH) fractures who are prescribed opioid medications at discharge from a baseline of 40% to 10% within 6 months. Setting/Local Problem: The study took place at an urban level 1 trauma center at a children’s hospital. The orthopaedic team completed closed reduction and percutaneous pinning for SCH fractures over a 14-month baseline period. Forty percent of these patients were discharged with an opioid prescription. After assessing baseline prescription rates, a multidisciplinary team of health professionals developed a key driver diagram. Interventions: Primary interventions included orthopedic department-wide pain management education, reporting of prescription rates during monthly conferences, and provider-specific feedback. The primary measure was the percentage of patients prescribed opioids upon discharge following closed reduction and percutaneous pinning of Type II and III SCH fractures. As a balancing measure, we tracked the use of a 24-hour nurse triage line for pain-related follow-up in the intervention period. We used statistical process control to examine changes in measures over time. Results: The percentage of patients receiving opioid prescriptions upon discharge following surgically treated SCH fractures decreased from 40% to 8% over 5 months and sustained for an additional 16 months. Conclusions: Through provider education, feedback, and regular reporting, we decreased the number of pediatric patients with surgically treated SCH fractures that were discharged with any opioid prescription by 80% over 5 months while ensuring clinically adequate pain control.
{"title":"A Quality Improvement Initiative to Reduce Opioid Prescriptions Following Surgical Treatment of Supracondylar Humerus Fractures in Children","authors":"Garrett E. Rupp, Joanna L. Langner, Claire E. Manhard, Amy W. Bryl, V. Upasani","doi":"10.55275/jposna-2023-696","DOIUrl":"https://doi.org/10.55275/jposna-2023-696","url":null,"abstract":"Background: Opioid abuse and overdose are in epidemic range in the United States and medical prescriptions, including those for postoperative analgesia, are a large contributing source to this misuse. Our quality improvement initiative aimed to reduce the opioid prescribing of pediatric orthopaedic surgeons in the postoperative setting. The aim was to decrease the percentage of children with surgically treated supracondylar humerus (SCH) fractures who are prescribed opioid medications at discharge from a baseline of 40% to 10% within 6 months. Setting/Local Problem: The study took place at an urban level 1 trauma center at a children’s hospital. The orthopaedic team completed closed reduction and percutaneous pinning for SCH fractures over a 14-month baseline period. Forty percent of these patients were discharged with an opioid prescription. After assessing baseline prescription rates, a multidisciplinary team of health professionals developed a key driver diagram. Interventions: Primary interventions included orthopedic department-wide pain management education, reporting of prescription rates during monthly conferences, and provider-specific feedback. The primary measure was the percentage of patients prescribed opioids upon discharge following closed reduction and percutaneous pinning of Type II and III SCH fractures. As a balancing measure, we tracked the use of a 24-hour nurse triage line for pain-related follow-up in the intervention period. We used statistical process control to examine changes in measures over time. Results: The percentage of patients receiving opioid prescriptions upon discharge following surgically treated SCH fractures decreased from 40% to 8% over 5 months and sustained for an additional 16 months. Conclusions: Through provider education, feedback, and regular reporting, we decreased the number of pediatric patients with surgically treated SCH fractures that were discharged with any opioid prescription by 80% over 5 months while ensuring clinically adequate pain control.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"35 6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114278351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-706
James D. Ortiz, James Barsi
Septic arthritis and Lyme arthritis are two conditions that can present with similar symptoms, making it challenging to differentiate between them in a clinical setting. While septic arthritis often requires immediate surgical intervention, Lyme arthritis can often be managed effectively with antibiotic therapy alone. However, given the dangerous nature of untreated septic arthritis, accurate diagnosis and timely intervention is crucial in managing the condition, especially in the pediatric population. Efforts to distinguish between the two conditions include the use of laboratory tests, history & physical exam findings, and MRI imaging. The authors aim to explore the causes, presentation, and treatment of septic versus Lyme arthritis, as well as to provide a summary of the evolving research in this area and propose an algorithm that can aid in diagnosis. By synthesizing the proposed algorithm in diagnosis, clinicians will be better equipped to manage septic versus Lyme arthritis effectively while avoiding invasive procedures such as joint aspiration.
{"title":"Differentiating Between Septic Arthritis and Lyme Arthritis in the Pediatric Population","authors":"James D. Ortiz, James Barsi","doi":"10.55275/jposna-2023-706","DOIUrl":"https://doi.org/10.55275/jposna-2023-706","url":null,"abstract":"Septic arthritis and Lyme arthritis are two conditions that can present with similar symptoms, making it challenging to differentiate between them in a clinical setting. While septic arthritis often requires immediate surgical intervention, Lyme arthritis can often be managed effectively with antibiotic therapy alone. However, given the dangerous nature of untreated septic arthritis, accurate diagnosis and timely intervention is crucial in managing the condition, especially in the pediatric population. Efforts to distinguish between the two conditions include the use of laboratory tests, history & physical exam findings, and MRI imaging. The authors aim to explore the causes, presentation, and treatment of septic versus Lyme arthritis, as well as to provide a summary of the evolving research in this area and propose an algorithm that can aid in diagnosis. By synthesizing the proposed algorithm in diagnosis, clinicians will be better equipped to manage septic versus Lyme arthritis effectively while avoiding invasive procedures such as joint aspiration.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"200 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116151931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-560
Mason A. Fawcett, R. Schwend
Background: Proximal junctional failure (PJF) is a known complication following posterior spinal fusion surgery and can be defined simply as proximal junctional kyphosis that requires surgical revision of the proximal instrumentation. PJF can be associated with pain, decreased neurologic function, infection, and increased morbidity. There is little literature on this topic in children and especially on specific surgical techniques for revision surgery. Methods: The revision technique involves extending the spine instrumentation proximally with paired sets of sublaminar bands used as anchors. Posterior osteotomies are typically required at the level of the kyphosis. The bands are gradually and sequentially tightened, bringing the spine into a corrected sagittal position. Patients who underwent this procedure and had at least 1 year of follow-up were identified. Demographic and clinical data, as well as plain radiographic and CT sagittal spine parameters, were analyzed before the surgery and at the most recent follow-up. Results: Eight children, average age 14 years, 10 months, were included in the study with an average follow-up time of 31 months. Revision surgery occurred approximately 3 years following the initial surgery. There was 20 degrees (ranging from an increase of 18° to a decrease of 46 degrees) mean kyphotic angle correction at the site of the failure and 16 degrees (ranging from an increase of 24 degrees to a decrease of 78 degrees) mean cervical lordosis correction, using an average of 6 sublaminar bands. Before revision, all patients reported neck/upper back pain, with upper rod prominence. At the most recent post-revision visit, pain was markedly reduced, and rod prominence had resolved. One patient reported increased satisfaction with appearance, and another noted that maintaining horizontal gaze was easier. Conclusion: Children who received this surgical technique for their PJF experienced resolution of pain and upper rod prominence and improved cervical spine sagittal radiographic parameters that was maintained at least 1 year after revision surgery.
{"title":"An Effective and Safe Surgical Technique for Salvage of Postoperative Proximal Junctional Failure in Pediatric Patients—A Case Series","authors":"Mason A. Fawcett, R. Schwend","doi":"10.55275/jposna-2023-560","DOIUrl":"https://doi.org/10.55275/jposna-2023-560","url":null,"abstract":"Background: Proximal junctional failure (PJF) is a known complication following posterior spinal fusion surgery and can be defined simply as proximal junctional kyphosis that requires surgical revision of the proximal instrumentation. PJF can be associated with pain, decreased neurologic function, infection, and increased morbidity. There is little literature on this topic in children and especially on specific surgical techniques for revision surgery. Methods: The revision technique involves extending the spine instrumentation proximally with paired sets of sublaminar bands used as anchors. Posterior osteotomies are typically required at the level of the kyphosis. The bands are gradually and sequentially tightened, bringing the spine into a corrected sagittal position. Patients who underwent this procedure and had at least 1 year of follow-up were identified. Demographic and clinical data, as well as plain radiographic and CT sagittal spine parameters, were analyzed before the surgery and at the most recent follow-up. Results: Eight children, average age 14 years, 10 months, were included in the study with an average follow-up time of 31 months. Revision surgery occurred approximately 3 years following the initial surgery. There was 20 degrees (ranging from an increase of 18° to a decrease of 46 degrees) mean kyphotic angle correction at the site of the failure and 16 degrees (ranging from an increase of 24 degrees to a decrease of 78 degrees) mean cervical lordosis correction, using an average of 6 sublaminar bands. Before revision, all patients reported neck/upper back pain, with upper rod prominence. At the most recent post-revision visit, pain was markedly reduced, and rod prominence had resolved. One patient reported increased satisfaction with appearance, and another noted that maintaining horizontal gaze was easier. Conclusion: Children who received this surgical technique for their PJF experienced resolution of pain and upper rod prominence and improved cervical spine sagittal radiographic parameters that was maintained at least 1 year after revision surgery.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"65 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114225198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-651
Ian P. Erkkila, Christopher A. Reynolds, Joshua P. Weissman, O. Levine, Hunter Aronson, Justin Knoll, J. Larson
Background: Adolescent idiopathic scoliosis (AIS) is a common referral to pediatric orthopaedic surgeons. Timely treatment with appropriate bracing decreases the risk of curve progression and need for surgical intervention. Despite pediatrician screening, patients still present to orthopaedic surgeons with curve magnitudes too significant for appropriate nonoperative bracing. Methods: This retrospective cross-sectional study included patients aged 10 to 18 years diagnosed with AIS between 2011-2021 at a major metropolitan tertiary care center. Patients were excluded if initial radiographs were obtained more than 1 week after clinical diagnosis. Scoliosis severity was classified based on initial radiographs. Sociodemographic factors were recorded, including patient addresses, which were cross-referenced with the diversitydatakids.org Child Opportunity Index (COI) database, which analyzes the quality of resources in a geographic area. Results: Gender, health insurance provider, race/ethnicity, and COI were all found to have a statistically significant relationship with CA and age at initial presentation. The odds of presenting with severe (versus mild and moderate) scoliosis was 2.3 times higher for patients who identified as black/African American compared to those who identified as white. Additionally, the odds of initially presenting with severe scoliosis were almost 40% higher in females compared to males. Furthermore, each stepwise increase in COI was associated with a 17%-19% decrease in odds of presenting with severe scoliosis, depending on standardization. Conclusions: There are sociodemographic disparities in the identification and initiation of treatment for AIS. Specifically, the odds of presenting with severe scoliosis are increased in patients who identify as black/African American or female and/or come from areas with lower access to resources (as defined by COI). Appropriate and timely referral to a pediatric orthopaedic surgeon for AIS treatment thus requires 1) educating primary care providers, pediatricians, and scoliosis screeners on how to appropriately identify scoliosis and the risks associated with late identification/referral and 2) public health initiatives to address access to care for patients at risk for late scoliosis identification.
{"title":"Factors Associated with Presentation of Severe Adolescent Idiopathic Scoliosis","authors":"Ian P. Erkkila, Christopher A. Reynolds, Joshua P. Weissman, O. Levine, Hunter Aronson, Justin Knoll, J. Larson","doi":"10.55275/jposna-2023-651","DOIUrl":"https://doi.org/10.55275/jposna-2023-651","url":null,"abstract":"Background: Adolescent idiopathic scoliosis (AIS) is a common referral to pediatric orthopaedic surgeons. Timely treatment with appropriate bracing decreases the risk of curve progression and need for surgical intervention. Despite pediatrician screening, patients still present to orthopaedic surgeons with curve magnitudes too significant for appropriate nonoperative bracing. Methods: This retrospective cross-sectional study included patients aged 10 to 18 years diagnosed with AIS between 2011-2021 at a major metropolitan tertiary care center. Patients were excluded if initial radiographs were obtained more than 1 week after clinical diagnosis. Scoliosis severity was classified based on initial radiographs. Sociodemographic factors were recorded, including patient addresses, which were cross-referenced with the diversitydatakids.org Child Opportunity Index (COI) database, which analyzes the quality of resources in a geographic area. Results: Gender, health insurance provider, race/ethnicity, and COI were all found to have a statistically significant relationship with CA and age at initial presentation. The odds of presenting with severe (versus mild and moderate) scoliosis was 2.3 times higher for patients who identified as black/African American compared to those who identified as white. Additionally, the odds of initially presenting with severe scoliosis were almost 40% higher in females compared to males. Furthermore, each stepwise increase in COI was associated with a 17%-19% decrease in odds of presenting with severe scoliosis, depending on standardization. Conclusions: There are sociodemographic disparities in the identification and initiation of treatment for AIS. Specifically, the odds of presenting with severe scoliosis are increased in patients who identify as black/African American or female and/or come from areas with lower access to resources (as defined by COI). Appropriate and timely referral to a pediatric orthopaedic surgeon for AIS treatment thus requires 1) educating primary care providers, pediatricians, and scoliosis screeners on how to appropriately identify scoliosis and the risks associated with late identification/referral and 2) public health initiatives to address access to care for patients at risk for late scoliosis identification.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"96 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114842774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-564
Jared A Nowell, R. Murray, M. Oetgen, B. Martin
Background: Fractures are typically evaluated and monitored using plain radiographs, but in the pediatric population the goal is always to reduce radiation exposure when possible. Dual-energy x-ray absorptiometry (DEXA) is an imaging modality that uses less radiation. The evaluation of upper and lower extremity fractures in the pediatric population using DEXA imaging has not yet been studied. Method: Radiographs of 19 patients treated for forearm or tibia fractures were compared to images taken with a DEXA machine. The angulation and translation of the fractures were measured twice each by two independent observers. Correlation of these values between plain radiographs and DEXA scans along with intra and inter-observer reliability was calculated. Results: A total of 19 patients with a forearm or tibia fracture were enrolled in the study. Correlation with conventional radiographs for angulation was r=0.77, p<0.001, while for translation it was r=0.76, p<0.001. The mean difference between the methods was 0.5 degrees (range of -6.7 to 7.7) for angulation and 4% (range of -28% to 37%) for translation. For plain radiographs, the inter-rater reliability was 0.90 (95% confidence interval of 0.84-0.93) for angulation and 0.89 (0.68-0.95) for translation. The inter-rater reliability for DEXA imaging was 0.77 (0.69-0.83) for angulation and 0.76(0.41-0.88) for translation. Conclusion: Our study showed that DEXA imaging correlates well with plain radiographs when measuring angulation and translation of forearm and tibia fractures in the pediatric population. This study is a proof of concept that DEXA, a low-dose radiation alternative to plain radiographs, may be useful in the management of pediatric fractures.
{"title":"Decreasing Radiation Exposure in the Treatment of Pediatric Long Bone Fractures Using a DXA Scan: A Proof of Concept","authors":"Jared A Nowell, R. Murray, M. Oetgen, B. Martin","doi":"10.55275/jposna-2023-564","DOIUrl":"https://doi.org/10.55275/jposna-2023-564","url":null,"abstract":"Background: Fractures are typically evaluated and monitored using plain radiographs, but in the pediatric population the goal is always to reduce radiation exposure when possible. Dual-energy x-ray absorptiometry (DEXA) is an imaging modality that uses less radiation. The evaluation of upper and lower extremity fractures in the pediatric population using DEXA imaging has not yet been studied. Method: Radiographs of 19 patients treated for forearm or tibia fractures were compared to images taken with a DEXA machine. The angulation and translation of the fractures were measured twice each by two independent observers. Correlation of these values between plain radiographs and DEXA scans along with intra and inter-observer reliability was calculated. Results: A total of 19 patients with a forearm or tibia fracture were enrolled in the study. Correlation with conventional radiographs for angulation was r=0.77, p<0.001, while for translation it was r=0.76, p<0.001. The mean difference between the methods was 0.5 degrees (range of -6.7 to 7.7) for angulation and 4% (range of -28% to 37%) for translation. For plain radiographs, the inter-rater reliability was 0.90 (95% confidence interval of 0.84-0.93) for angulation and 0.89 (0.68-0.95) for translation. The inter-rater reliability for DEXA imaging was 0.77 (0.69-0.83) for angulation and 0.76(0.41-0.88) for translation. Conclusion: Our study showed that DEXA imaging correlates well with plain radiographs when measuring angulation and translation of forearm and tibia fractures in the pediatric population. This study is a proof of concept that DEXA, a low-dose radiation alternative to plain radiographs, may be useful in the management of pediatric fractures.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"105 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133723634","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-731
Kyle S. Chen, Daniel McBride, J. Wild, Soyang Kwon, J. Samet, R. Gibly
Introduction: Acute musculoskeletal infections (MSKi) affect >1:6000 children in the United States annually, which could lead to arthritis, chronic infection, limb deformity, and even death. MRI is the gold standard for MSKi diagnosis but traditionally requires contrast and anesthesia, delaying results and slowing treatment decision-making. A rapid MRI protocol is an unsedated MRI with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to help identify abscesses. The objective of this study was to compare MRI access, timing, treatment, length of stay, and charges between the traditional and rapid MRI protocols among pediatric patients undergoing MSKi evaluation. Methods: A single-center retrospective study was conducted among 128 patients undergoing MSKi evaluation before (“Traditional cohort” [TC] of 60 patients admitted in Jan-Dec 2019) and after implementation of the Rapid MRI protocol (“Rapid cohort” [RC] of 68 patients admitted in Jun 2021-Jul 2022). Demographic, clinical, and charge data were extracted from electronic health records. Mann-Whitney U tests were performed to compare the two groups. Results: Demographics and diagnoses were similar, while rates of sedation and contrast administration were significantly different (53% and 88% in TC versus 4% and 0% in RC). The median time to MRI after ordering was 6.5 hours (IQR=3.2-12.2) in TC and 2.2 hours (IQR=1.1-4.5) in RC (P<0.01). The median duration of MRI was 63.2 minutes (IQR=52.4-85.3) in TC and 24.0 minutes (IQR=18.5-41.1) in RC (P<0.01). The median time between ordering and receiving the MRI final interpretation was 13.5 hours (IQR=2.35-66.3) in TC and 7.0 hours (IQR=1.25- 41.7) in RC (P<0.01). The median hospital length of stay was 5.3 days (IQR=2.7-7.9) in TC and 3.7 days (IQR=1.0-5.8) in RC (P<0.01). The median charges for the entire hospital stay were $48,015 (IQR=$28,086-$88,496) in TC and $33,532 (IQR=$13,622, $54,710) in RC (P<0.01). While 10/68 of Rapid MRIs were canceled or aborted due to patient motion or pain, only 6/68 required repeat MRI with sedation. No infection diagnoses were missed on Rapid imaging. Conclusion: In patients being evaluated for MSKi, the Rapid MRI protocol eliminated contrast and nearly eliminated sedation while leading to improved MRI access, scan and interpretation times, and significant decreases in hospital length of stay and charges. Future steps include continuing quality control, studying interobserver reliability between protocols, and multicenter program expansion. Significance: Pediatric MSKi carry a large treatment burden, and this Rapid MRI protocol improves imaging access while eliminating contrast, decreasing sedation, scan time, length of stay, and hospital charges, with a <10% rescan rate and without missing actionable diagnoses.
简介:在美国，急性肌肉骨骼感染(MSKi)每年影响超过1:6000的儿童，这可能导致关节炎、慢性感染、肢体畸形甚至死亡。MRI是MSKi诊断的金标准，但传统上需要造影剂和麻醉，延迟了结果，减慢了治疗决策。快速MRI方案是一种非镇静MRI，具有有限的非对比序列，优化了液体检测和扩散加权图像，以帮助识别脓肿。本研究的目的是比较传统和快速MRI方案在接受MSKi评估的儿科患者中的MRI访问、时间、治疗、住院时间和费用。方法:对128例接受MSKi评估的患者(60例2019年1- 12月入院的“传统队列”[TC])和实施快速MRI方案后(68例2021年6月- 2022年7月入院的“快速队列”[RC])进行单中心回顾性研究。从电子健康记录中提取人口统计、临床和收费数据。采用Mann-Whitney U检验对两组进行比较。结果:人口统计学和诊断率相似，而镇静和造影剂使用率显著不同(TC为53%和88%，而RC为4%和0%)。TC组下单后到MRI的中位时间为6.5 h (IQR=3.2 ~ 12.2)， RC组为2.2 h (IQR=1.1 ~ 4.5) (P<0.01)。MRI中位持续时间TC组为63.2 min (IQR=52.4 ~ 85.3)， RC组为24.0 min (IQR=18.5 ~ 41.1) (P<0.01)。TC组下单至接受MRI最终解释的中位时间为13.5小时(IQR=2.35 ~ 66.3)， RC组为7.0小时(IQR=1.25 ~ 41.7) (P<0.01)。TC组中位住院时间为5.3 d (IQR=2.7 ~ 7.9)， RC组中位住院时间为3.7 d (IQR=1.0 ~ 5.8) (P<0.01)。整个住院期间的中位数费用为TC组$48,015 (IQR=$28,086-$88,496)， RC组$33,532 (IQR=$13,622， $54,710) (P<0.01)。而10/68的快速MRI因患者运动或疼痛而取消或流产，只有6/68需要在镇静下重复MRI。快速显像无感染漏诊。结论:在接受MSKi评估的患者中，快速MRI方案消除了造影剂和几乎消除了镇静，同时改善了MRI访问、扫描和解释时间，并显着减少了住院时间和费用。未来的步骤包括继续进行质量控制，研究协议之间的观察者之间的可靠性，以及多中心程序扩展。意义:小儿MSKi承担着巨大的治疗负担，而这种快速MRI方案改善了成像途径，同时消除了造影剂，减少了镇静、扫描时间、住院时间和住院费用，重新扫描率<10%，并且没有遗漏可操作的诊断。
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Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-683
Alex Villegas, A. Whitaker
Gun injuries are now the leading cause of death in children. This arises from increased access to guns across the U.S. More firearm injuries are presenting to emergency departments and non-trauma centers. We identified 52,414 children with firearm injuries, including 19,583 extremities. Most were treated with antibiotics, bedside I&D, and non-operative stabilization for simple wounds of <1 cm without contamination and stable fracture patterns. More complex injuries with larger soft tissue defects usually caused by high-velocity weapons with contamination, bone loss, operative fracture patterns, intraarticular projectiles, vascular injuries, compartment syndromes, and nerve injuries warrant further treatment in the operating room and IV antibiotics. Only 28% of nerve injuries regained function. Loss to follow-up was high (43%). Growth arrest and lead toxicity are long-term sequelae that must be monitored, especially given the decrease in acceptable blood lead levels to <3.5 mg/dL by the CDC in 2020. Evaluation of the child’s environment and access to guns and education is important for preventing future injuries on an individual level, however, research and legislation are needed to decrease this epidemic of gun violence injuring and killing children today.
{"title":"Best Practices for Orthopaedic Treatment of Pediatric Gunshot Injuries","authors":"Alex Villegas, A. Whitaker","doi":"10.55275/jposna-2023-683","DOIUrl":"https://doi.org/10.55275/jposna-2023-683","url":null,"abstract":"Gun injuries are now the leading cause of death in children. This arises from increased access to guns across the U.S. More firearm injuries are presenting to emergency departments and non-trauma centers. We identified 52,414 children with firearm injuries, including 19,583 extremities. Most were treated with antibiotics, bedside I&D, and non-operative stabilization for simple wounds of <1 cm without contamination and stable fracture patterns. More complex injuries with larger soft tissue defects usually caused by high-velocity weapons with contamination, bone loss, operative fracture patterns, intraarticular projectiles, vascular injuries, compartment syndromes, and nerve injuries warrant further treatment in the operating room and IV antibiotics. Only 28% of nerve injuries regained function. Loss to follow-up was high (43%). Growth arrest and lead toxicity are long-term sequelae that must be monitored, especially given the decrease in acceptable blood lead levels to <3.5 mg/dL by the CDC in 2020. Evaluation of the child’s environment and access to guns and education is important for preventing future injuries on an individual level, however, research and legislation are needed to decrease this epidemic of gun violence injuring and killing children today.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"130 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130507872","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01DOI: 10.55275/jposna-2023-727
Amelia M. Lindgren, Alexander M. Lieber, Suken A. Shah, M. Thacker
Atypical slipped capital femoral epiphyseal (SCFE) is associated with endocrine or metabolic disorders and radiation therapy. In this review, we discuss the clinical presentation for endocrinopathies, such as hyperparathyroidism, hypothyroidism, and growth hormone deficiency as well as renal osteodystrophy, radiation-induced, and valgus SCFE, with pertinent case examples. Routine laboratory screening of all patients with SCFE is likely not cost-effective. Patients with atypical SCFE are often short in stature, underweight, and present either older or younger than the typical age range (10-16 years old) of idiopathic SCFE. Patient’s fitting these criteria should undergo an endocrine workup. While uncommon, prompt recognition of atypical SCFE is crucial as coordinated care with pediatric subspecialists is necessary. In situ fixation with cannulated screws is the most common fixation method and bilateral fixation is recommended.
{"title":"Management of Atypical Slipped Capital Femoral Epiphysis","authors":"Amelia M. Lindgren, Alexander M. Lieber, Suken A. Shah, M. Thacker","doi":"10.55275/jposna-2023-727","DOIUrl":"https://doi.org/10.55275/jposna-2023-727","url":null,"abstract":"Atypical slipped capital femoral epiphyseal (SCFE) is associated with endocrine or metabolic disorders and radiation therapy. In this review, we discuss the clinical presentation for endocrinopathies, such as hyperparathyroidism, hypothyroidism, and growth hormone deficiency as well as renal osteodystrophy, radiation-induced, and valgus SCFE, with pertinent case examples. Routine laboratory screening of all patients with SCFE is likely not cost-effective. Patients with atypical SCFE are often short in stature, underweight, and present either older or younger than the typical age range (10-16 years old) of idiopathic SCFE. Patient’s fitting these criteria should undergo an endocrine workup. While uncommon, prompt recognition of atypical SCFE is crucial as coordinated care with pediatric subspecialists is necessary. In situ fixation with cannulated screws is the most common fixation method and bilateral fixation is recommended.","PeriodicalId":412478,"journal":{"name":"Journal of the Pediatric Orthopaedic Society of North America","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117045524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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