Limb fracture pattern in different pediatric age groups: a study of 3,350 children

Wrist and elbow fracture detection and segmentation by artificial intelligence using point-of-care ultrasound

PURPOSE

Distal radius (wrist) and supracondylar (elbow) fractures are common in children presenting to Pediatric Emergency Departments (EDs). These fractures are treated conservatively or surgically depending on deformity severity. Radiographs are typically used for diagnosis but can increase wait times due to the need for radiation-safe rooms. Ultrasound (US) offers a radiation-free, faster alternative that can be performed at triage, but its noisy images are challenging to interpret.

METHODS

We developed an artificial intelligence (AI) technique for the automatic diagnosis of fractures at the wrist and elbow. While most AI for diagnosis focuses on classification results only, we applied a more explainable pipeline that used US bony region segmentation from a CNN as the basis of fracture detection. Our approach was validated on 3,822 wrist US images and 1487 elbow US images. We compared the fracture detection results from classification models and multi-channel segmentation models.

RESULTS

Combining the segmentation results with the original images showed superior performance in fracture detection at the individual patient level, achieving an accuracy of 0.889 and 0.750, sensitivity of 0.818 and 1.000, and specificity of 1.000 and 0.714 on the wrist and elbow dataset respectively. Besides, the multi-channel U-Net architecture effectively detected bony fracture regions in wrist US images.

CONCLUSION

These findings demonstrate that AI models can enable reliable, automatic wrist and elbow fracture detection in pediatric EDs, potentially reducing wait times and optimizing medical resource use.

Reliability of radiographic union score and correlation of clinical outcomes in children operated for supracondylar humerus fracture: A prospective study

Background

Supracondylar humerus fractures are common in childhood, and postoperative follow-up planning for surgically treated fractures is still controversial. This study aims to investigate the interobserver and intraobserver reliability of the Radiographic Union Score for Tibial Fracture in the postoperative radiological follow-up of pediatric supracondylar humerus fractures and to evaluate the clinical results with the scores obtained during follow-up.

Methods

In this prospective study, patients who were operated on for supracondylar humerus fractures were called for follow-up three times: postoperative splint removal, pin removal, and final control. A total of 58 patients, 34 boys and 24 girls, who provided regular follow-ups, were included in the study. During follow-ups, the Radiographic Union Score for Tibial Fracture was calculated by evaluating the patients' elbow anteroposterior and lateral radiographs, and the elbow joint range of motion was recorded with a goniometer. In two experiments, orthopedic surgeons evaluated intraobserver and interobserver reliability using the intraclass correlation coefficient at different times. The patients were evaluated at the last follow-up according to the Flynn criteria.

Results

The first follow-up Radiographic Union Score for Tibial Fracture (median (range) was 8 (7-10), the second follow-up was 11 (9-12), and the third follow-up was 12 (11-12). Range of motion was 40° at the first follow-up, 90° at the second follow-up, and 120° at the third follow-up. Radiographic Union Score for Tibial Fracture and range of motion increased significantly as the weeks progressed (p < 0.001). Interobserver intraclass correlation coefficient at first follow-up was 0.80 (95% confidence interval 0.69-0.87), second follow-up was 0.85 (0.77-0.91), and third follow-up was 0.79 (0.67-0.87). Intraobserver intraclass correlation coefficient was 0.92 (0.88-0.95) at the first follow-up, 0.93 (0.98-0.96) at the second follow-up, and 1.00 (1.00-1.00) at the third follow-up. Flynn score results are functional; the cosmetic results were excellent in 46 patients, good in 4 patients, fair in 5 patients, poor in 3 patients, and cosmetic results were excellent in 54 patients and good in 4 patients.

Conclusion

Our study determined that the radiographic union of fractures in pediatric supracondylar humerus fractures is reliably evaluated with the Radiographic Union Score for Tibial Fracture score. Radiographic Union Score for Tibial Fracture can be used to provide data-driven estimates of splint and pin removal.

Level of evidence

Level II, prospective study.

The Limited Significance of the Internal Rotation Stress Test in Pediatric Gartland Type III Supracondylar Humerus Fractures

Background: Gartland type III pediatric supracondylar humerus fractures can be unstable and prone to loss of reduction. The Internal Rotational Stress Test (IRST) aims to assess and address rotational instability during surgery. Method: This retrospective study analyzed treatments for Gartland type III pediatric supracondylar humerus fractures at our institution from January 2020 to December 2022. Only patients who underwent IRST were included. IRST was performed after inserting either two or three lateral pins. Patients were divided into Group 1 (IRST +) or 2 (IRST -) based on IRST results. Radiographic and clinical outcomes were compared between the two groups. Result: A total of 46 patients were included in the study. The mean age at the time of diagnosis was 5.7 years (range, 4 to 11 years), and the mean duration of follow-up was 2.8 years (range, 1.0 to 4.8 years). Group 1 consisted of 24 patients, and Group 2 comprised 22 patients. We did not find any differences in radiographic parameters and clinical scores between the two groups. Additionally, in both groups, there were no instances of major loss of reduction, defined as greater than 12 degrees or 12%. In five patients, we identified two types of fracture patterns that were stable with only two lateral pins. Conclusions: In patients with Gartland type III supracondylar humerus fractures, if reduction is adequately achieved and sufficient fixation force is maintained, the IRST results do not significantly impact radiologic and clinical outcomes. The pattern of the fracture can influence instability, necessitating further research on this matter.

Multicenter epidemiological analysis of related factors in 10,808 hospitalized children with lower limb and pelvic fractures in China

To analyze the causes, locations, associated injuries, and relevant factors of lower limb and pelvic fractures in hospitalized children in China to provide a theoretical basis for reducing the incidence of such fractures. A retrospective analysis of children with lower limb and pelvic fractures admitted to 27 tertiary children's hospitals affiliated with China's Futang Research Center of Pediatric Development between December 1, 2015, and December 31, 2019, was conducted. Inpatient cases were analyzed in the following age groups: Infants (< 2 years), Preschool children (2-5 years), School children (6-11 years), and Adolescents (12-18 years). This study included 10,808 pediatric patients (7152 males, 3656 females). The proportion of preschool children of lower limb and pelvic fractures was the highest. The 10,808 patients sustained a total of 14,398 fractures. The shafts of the femur, tibia, and fibula, the distal tibia, distal fibula, and the pelvis were the six most common locations. Of the 734 pelvic fractures in children and adolescents, the top three locations were the ilium, pubic bone, and the ischium. Of the total patients, 9599 underwent surgery, while 1209 received non-surgical treatment. The three most common causes of pediatric lower limb and pelvic fractures were falling over, traffic accidents, and falling from a height. Among the 1806 concomitant traumas, respiratory traumas was the most common, mainly pulmonary contusion. The most common concomitant traumas of nervous, digestive and urinary system were scalp hematoma, liver injury and kidney injury respectively. The analysis of the location, age, causes, and concomitant injuries of lower limb and pelvic fractures showed that the most common fracture requiring hospitalization was tibia fracture, which was most common in preschool children. The most common cause of injury in preschool children was traffic accident. In addition, children are susceptible to accidental injuries from multiple sources in life, which can cause serious consequences of multi-system injuries.

Minimal intervention (removable splint or bandage) for the management of distal forearm fractures in children and adolescents: A scoping review

INTRODUCTION

Distal forearm fractures are common in children and adolescents with a spectrum of severity. There are fracture patterns that are suitable for minimal interventions, such as a splint or bandage. The objective of this review was to identify which types of paediatric distal forearm fractures can be safely and effectively managed with a removable splint or bandage.

MATERIALS AND METHODS

A scoping review was performed. Databases searched were PubMed, Embase, The Cochrane Library and CINAHL; two trial registries were also searched. All primary study designs with children <18 years of age with a distal forearm fracture that was managed in either a splint or bandage were included. Quality of evidence was determined using the GRADE tool.

RESULTS

Twenty-two eligible articles were included from 20 unique studies: 12 randomised controlled trials, seven cohort studies and a case report. Twelve studies focused solely on buckle/torus fractures, with remaining studies including other fracture types, such as incomplete ('greenstick'), complete ('transverse'), or physeal (Salter-Harris). Twelve studies reported that participants with either bandage or splint had appropriate reduction in pain and recovery of function at completion of follow-up for all fracture types. All 20 studies reported minimal adverse events related to fracture management. One study reported worsening angulation with bandage immobilisation for complete fractures in two participants, which required manipulation under anaesthesia.

DISCUSSION

There is high quality evidence to support the safety and effectiveness of a splint or bandage for treatment of distal radius buckle and non-displaced incomplete fractures. Several studies supported the use of minimal interventions for various distal radius cortical breach fracture types, with good outcomes, but were limited by heterogeneity (methodology, interventions, outcome measures, reference standard) and potential bias.

CONCLUSIONS

Included studies confirmed the inherent stability of buckle fractures. The current literature gap to support minimal interventions for a range of other paediatric distal forearm fracture types was highlighted. High-quality evidence with well-designed, large, multicentre randomised control trials in defined age groups is required to identify which paediatric distal forearm fractures can be safely and effectively managed with either a removable splint or bandage.

Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?

BACKGROUND

For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.

QUESTIONS/PURPOSES

In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?

METHODS

In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.

RESULTS

At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).

CONCLUSION

In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Ipsilateral Supracondylar and Medial Epicondyle Humerus Fractures in Pediatric Patients: A Retrospective Analysis of Incidence, Epidemiology, Treatment, and Outcomes

BACKGROUND

Pediatric supracondylar humerus (SCH; AO/OTA13-M/3.1) and medial epicondyle fractures (AO/OTA13u-M/7.1) are common. Concomitant SCH with ipsilateral medial epicondyle fractures remain scarcely reported. We investigated the epidemiology, treatment, and outcomes of this rare, combined injury.

METHODS

A retrospective review of pediatric patients with concomitant SCH and medial epicondyle fractures at a level 1 hospital from 2010 to 2020 was performed. Patient data, treatments, and outcomes were assessed. Radiographs were reviewed for fracture classification and alignment. Patients aged above 18 years and those with inaccessible imaging were excluded. Descriptive statistics were performed.

RESULTS

Of 3344 patients undergoing surgery for SCH fractures, 14 (6 females, mean: 10.59 y) with concomitant SCH and medial epicondyle fractures were included. Overall, 28.6% of patients exhibited preoperative nerve palsies (3 PIN, 1 median nerve). There was 1 flexion type and 13 Gartland type III SCH fractures. Medial epicondyle fracture displacement averaged 4.13 mm (range: 2 to 7 mm). Thirteen medial epicondyle fractures occurred medial to the physis with 1 through the physis. Eight patients (57.1%) had medial fixation-7 medial pins, 1 medial screw-which captured both the medial epicondyle and medial column of the SCH fracture. Six medial epicondyles were treated closed. The average time to pin pull was 33.1 days (range: 27 to 51 d) with average follow-up of 138.6 days (range: 27 to 574 d). Overall, 50% of patients completed physical therapy (PT). Complications occurred in 4 cases: prominence of a medial pin, 1 patient required additional PT and dynamic splinting for loss of functional extension, 1 patient underwent a manipulation under anesthesia 3.5 months postoperatively for flexion contracture, and 1 patient developed medial epicondyle nonunion and SCH malunion that underwent corrective osteotomy 10.5 months postoperatively.

CONCLUSIONS

Concurrent SCH and medial epicondyle fractures exhibited a high rate of nerve palsy (28.6%) and complications (28.6%) and were frequently referred to physical therapy. While patients treated without medial fixation went on to union, this combined injury might represent a relative indication for medial pinning of the SCH fracture. Further studies on this rare injury pattern are needed to determine optimal treatment methods.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Cubitus varus deformity following paediatric supracondylar humeral fracture remodelling predominantly in the sagittal direction: A three-dimensional analysis of eighty-six cases

PURPOSE

Three-dimensional (3D) capacity for remodelling in cubitus varus deformity (CVD) after paediatric supracondylar humeral fractures (PSHFs) remains unelucidated. This study investigated remodelling patterns after PSHFs by examining 3D deformity distribution over time after injury.

METHODS

Computed tomography (CT) data of 86 patients with CVD after PSHFs were analysed. The 3D deformity angles in the sagittal, coronal, and axial directions were assessed and correlated with the duration between the age at injury and CT evaluation. For the subgroup analysis, we performed the same correlation analysis in a younger (< 8 years old) and an older group (≥ 8 years old); we categorized the duration into early (< 2 years), middle (≥ 2 to < 5 years), and late periods (≥ 5 years) and compared the deformity angles of each direction among the three groups.

RESULTS

Sagittal deformity showed a moderate correlation with the duration of deformity (r = -0.54; P < 0.001), while coronal and axial deformities showed a negligible correlation. Sagittal deformity showed moderate correlations with the duration in the younger group (r = -0.62; P < 0.001) and weak correlations in the older group (r = -0.37; P = 0.091). In the sagittal direction, the deformity angle in the early period was significantly larger than those in the mid and late periods (P < 0.001). However, there were no significant differences among the three groups in the coronal and axial directions.

CONCLUSION

Sagittal deformities in CVDs are capable of remodelling, especially in the early period and at a younger age, whereas coronal and axial deformities are less likely to undergo remodelling.

Flexed position of the wrist in the cast reliably prevents displacement after physeal Salter-Harris I and II distal radius fractures

BACKGROUND

Salter-Harris I and II fractures of the distal radius are common injuries. In our facility, immobilisation is performed in a way that counteracts angulation forces. The aim of our study was to determine whether there are significant differences between patients with and patients without a loss of reduction treated with this method and to determine what degree of flexion reliably prevents secondary displacement.

PATIENTS AND METHODS

We conducted a retrospective study of 112 patients (mean age: 12 years) who had sustained a Salter-Harris type I or II fracture of the distal radius and were treated with reduction. Patients were grouped according to fracture type and whether they sustained a loss of reduction or not. Patients were compared for gender, age, initial angulation, angulation after reduction, degree of flexion/extension of the wrist in the cast, residual angulation, duration of immobilisation, and complication rate. We also analysed whether a 45-degree flexed position of the wrist in plaster provides reliable protection against secondary displacement.

RESULTS

In group I, patients with no loss of reduction had a significantly greater degree of wrist flexion in the cast, a significantly shorter duration of immobilisation and significantly less residual angulation. Patients with an apex-volar deformity with the wrist immobilised at more than 45 degrees of flexion had no loss of reduction at all and had significantly less residual angulation compared with patients with the wrist immobilised at less than 45 degrees of flexion. In this patient group, loss of reduction was noted in 28% of cases. The patients in group II with loss of reduction showed a significantly higher angulation after the reduction. During the follow-up examination, one patient experienced physeal arrest followed by an ulnar impaction syndrome. Other complications recorded were minor.

CONCLUSIONS

In summary, based on our results, we recommend that all physeal fractures of the distal radius with an apex-volar angulation can be safely treated with reduction and immobilisation counteracting the forces of angulation. For apex-dorsal fractures, palmar flexion of 45° allows for reliable reduction.

The Gartland classification for expediting supracondylar humerus fracture triage: a collaborative approach to structured reporting between pediatric radiologists and orthopedists

BACKGROUND

The modified Gartland classification is an important tool for evaluation of pediatric supracondylar humerus fractures (SCHF) because it can direct treatment decisions. Gartland type I can be managed outpatient, while emergent surgical consult occurs with type II and III. This study assesses the interobserver reliability of the Gartland classification between pediatric radiologists and orthopedic providers.

METHODS

A retrospective review of 320 children diagnosed with a SCHF at a single tertiary children's hospital during 2022 was conducted. The Gartland classification documented in the radiographic report by a pediatric radiologist and the classification documented in the first encounter with an orthopedic provider was collected. Kappa value was used to assess interobserver reliability of classifications between radiologists and orthopedic providers. A second group of 76 Gartland type I SCHF from 2015, prior to our institution's implementation of structured reporting, was reviewed for comparison of unnecessary orthopedic consults at initial presentation.

RESULTS

The Gartland classification has excellent interobserver reliability between radiologists and orthopedic providers with 90 % (289/320) agreement and kappa of 0.854 (confidence interval: 0.805-0.903). The most frequent disagreement that occurred was fractures classified as type II by radiology and type III by orthopedics. There were similar rates of consults for the 2015 and 2022 cohorts (p = 0.26).

CONCLUSION

The Gartland classification system is a reliable and effective tool for communication between radiologists and orthopedic providers. Implementing a structured reporting system has the potential to improve triage efficiency for SCHF.

A bilateral four-headed brachialis muscle with a variant innervation: a cadaveric report with possible clinical implications

PURPOSE

Anterior compartment muscles of the arm present high morphological variability, with possible clinical significance. The current cadaveric report aims to describe a bilateral four-headed brachialis muscle (BM) with aberrant innervation. Emphasis on the embryological background and possible clinical significance are also provided.

METHODS

Classical upper limb dissection was performed on an 84-year-old donated male cadaver. The cadaver was donated to the Anatomy Department of the National and Kapodistrian University of Athens.

RESULTS

On the left upper limb, the four-headed BM was supplied by the musculocutaneous and the median nerves after their interconnection. On the right upper limb, the four-headed BM received its innervation from the median nerve due to the musculocutaneous nerve absence. A bilateral muscular tunnel for the radial nerve passage was identified, between the BM accessory heads and the brachioradialis muscle.

CONCLUSION

BM has clinical significance, due to its proximity to important neurovascular structures and frequent surgeries at the humerus. Hence, knowledge of these variants should keep orthopedic surgeons alert when intervening in this area. Further dissection studies with a standardized protocol are needed to elucidate the prevalence of BM aberrations and concomitant variants.

Modified Kapandji technique in pediatric displaced distal radius fractures: results in 195 patients

PURPOSE

The modified Kapandji technique has been proposed for fracture reduction in pediatric displaced distal radius fractures (DDRFs), but evidence is sparse. The purpose of this study was to evaluate our outcomes and complications, critically and systematically, when performing the modified Kapandji technique in pediatric DDRFs. Using this technique since 2011, we asked: (1) What is the quality of fracture reduction using this technique? (2) How stable is fracture alignment with this technique? (3) What are the postoperative complications and complication rates?

METHODS

Retrospective observational study of 195 pediatric patients treated with the modified Kapandji technique. Quality of fracture reduction, fixation type (intrafocal, combined, or extrafocal), and coronal/sagittal angulation were recorded at surgery and healing. Perioperative complications were graded. Patients were stratified by fracture (metaphyseal or Salter-Harris) and fixation type, as well as age (≤ 6 years; 6 to 10 years; > 10 years).

RESULTS

Fracture reduction was 'good' to 'anatomical' in 85% of patients. 'Anatomical' fracture reduction was less frequent in metaphyseal fractures (21% vs. 51%; p < .001). Mean angulation change was higher in metaphyseal fractures in both the sagittal (p = .011) and coronal (p = .021) planes. Metaphyseal fractures showed a higher mean change in sagittal angulation during fracture healing for the 'intrafocal' group. We observed a 15% overall complication rate with 1% being modified Sink Grade 3.

CONCLUSION

The modified Kapandji technique for pediatric DDRFs is a safe and effective treatment option. Metaphyseal fractures that do not involve the physis should be treated with extrafocal or combined wire fixation. Complications that require additional surgical treatment are rare.

LEVEL OF EVIDENCE

Level of evidence IV.

Increase in gap index over time after reduction of unstable paediatric both-bone forearm fracture does not cause displacement

This study investigated the effects of changes in the gap index on fracture displacement during follow-up. Patients who underwent closed reduction and casting with a diagnosis of unstable paediatric both-bone forearm fractures and a cast index < 0.8 were retrospectively evaluated. Patients were divided into Groups 1 and 2 based on their gap index (<0.15 and >0.15, respectively). Anteroposterior and lateral displacements of the radius and ulna and the gap index of the cast were measured on the X-ray after the first reduction and on the last X-ray before plaster removal. The mean patient age (n = 94, 74 boys and 20 girls; 51 in Group 1 and 43 in Group 2) was 7.09 ± 2.66 years. Fracture union times (plaster removal) were 38.8 ± 7.1 days. The mean cast index was 0.76 ± 0.05 (0.59-0.8). Both groups had similar distributions in terms of age, sex, fracture side, anatomic location and plaster removal time (p > 0.05). No significant differences were observed in either group in any radial or ulnar angulation values at any time point or the difference between the first and last values (all p > 0.05). Moreover, the gap index difference between the first and last measurements was significantly different in both groups (p = 0.002). If the cast index remains <0.8, despite the increase in the gap index in both groups, the amount of fracture displacement was small and acceptable.

Anatomical Variations of the Musculocutaneous Nerve in the Human Fetus

OBJECTIVES

Knowing the motor branches and variations of the musculocutaneous nerve to the muscles along its course will facilitate the treatment of flexor spasticity and supracondylar fractures of the humerus in order to minimize nerve lesion. In fetal cadavers, the purpose of our study was to determine the number and course of the formation variations and motor branches of the musculocutaneous nerve. The significance of studying fetal nerve variations is due to injury to the brachial plexus roots during birth.

METHODS

Our study was conducted using the anatomical dissection technique on 102 upper limbs from 51 fetuses ages ranged from 17 to 40 weeks. Throughout its course, the variations and motor branches of the musculocutaneous nerve were analyzed.

RESULTS

In 13.7% of cases, the musculocutaneous nerve did not pierce the coracobrachialis. The musculocutaneous nerve gave the muscles 1-3 motor branches. Additionally, motor branches terminated with 1-7 fringes. The biceps brachii motor branches of the musculocutaneous nerve were typed. Accordingly, 15.6% were type 1A, 3.9% were type 1B, 35.4% were type 1C, and 19.6% were type 1D. It was determined that 23.5% of the extremities were type 2 and that 1.9% were type 3. The distance between the musculocutaneous nerve's motor branches and the acromion was proportional to the arm's length. There were no statistically significant differences between the sides and genders for any measurement.

CONCLUSIONS

Our study's findings will aid in the diagnosis and treatment of pediatrics, orthopedics, surgical sciences, and radiology conditions. It reduces the risk of iatrogenic injury and postoperative complications. We also believe that our research will serve as a resource for anatomists and other scientists.

Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?

Supracondylar humerus fractures are common pediatric injuries encountered by orthopedic surgeons. Displaced fractures are treated operatively with closed reduction and percutaneous pinning or open reduction of injuries that cannot be adequately closed reduced. The purpose of this study is to identify preoperative injury characteristics associated with open reduction. Retrospective chart review was performed on all AO type 13A (Gartland type) supracondylar humerus fractures in patients 2-13 years old treated surgically at a single level 1 trauma center over 6 years. Preoperative demographics and radiographic parameters were obtained for all patients. Primary outcomes were closed reduction or conversion to open reduction of fractures prior to k-wire fixation. Initial bivariate analysis was done using Chi-square tests. Final multivariate analysis with Bonferonni correction was performed using a backward, stepwise regression model including potential predictor variables identified in the bivariate analysis. A total of 211 patients received surgical treatment and 18 of those patients (8.5%) failed closed reduction and underwent open reduction. Final multivariate analysis demonstrated that only flexion type [relative risk (RR), 10.2] and coronal displacement more than 7 mm (RR, 4.49) were significant preoperative factors for conversion to open reduction. Patients with significant coronal displacement and flexion-type injuries are markers of challenging reduction and are at high risk for conversion to open reduction.

Radiological and Clinical Outcomes of Pediatric Patients With a Supracondylar Humerus Fracture Surgically Treated With Closed Reduction and Percutaneous Pinning

OBJECTIVES

It was aimed to evaluate the clinical and radiological results of patients operated on with closed reduction and pinning due to pediatric supracondylar humerus fractures.

MATERIALS AND METHODS

The radiological and clinical results of 100 patients operated on with closed reduction and percutaneous pinning for pediatric supracondylar humerus fractures in the Department of Orthopedics and Traumatology were examined between January 2015 and February 2022. Clinical results were evaluated by performing cosmetic and functional scores defined by Flynn. Closed reduction and percutaneous pinning techniques were used in surgical treatment.

RESULTS

In our study, 59 patients were male (59%), and 41 were female (41%). The average age of all patients is 6.21 ± 2.85 years. According to the Gartland classification, 21 patients' fractures were type IIA (21%), 12 patients' fractures were type IIB (12%), 51 patients' fractures were type III (51%), and 16 patients' fractures were type IV (16%). The average number of pins used in the treatment is 2.55 ± 0.50. The elbow bearing angle of the operated side of the patients was an average of 6.53 ± 3.29 degrees, the humerocapitellar angle was an average of 41.97 ± 3.08 degrees, and the lateral humerocapitellar angle was an average of 50.17 ± 3.58 degrees. Fifty-one patients had stage 0 (51%), 23 patients had stage 1 (23%), 23 patients had stage 2 (23%), and three patients had stage 3 (3%) residual sagittal plane deformity. According to the Flynn criteria, 92 patients had excellent functional results (92%), seven patients had good results (7%), and one patient had fair results (1%). Regarding cosmetic results, 91 patients had excellent results (91%), six patients had good results (6%), and three patients had fair results (3%).

CONCLUSION

Supracondylar humerus fractures are common in children and can cause serious complications. Closed reduction and percutaneous pinning techniques are effective treatment methods in the treatment of displaced supracondylar humerus fractures.

Epidemiology of Paediatric Trauma During National Lockdown: A Retrospective Study With 12 Months of Follow-Up

Introduction The COVID-19 pandemic and its associated preventative measures such as national lockdown dramatically changed the daily activities of children. This paper aims to compare the epidemiology of paediatric orthopaedic trauma presentation, management and outcomes during the school closure period with the matched pre-pandemic period in 2019. Methods This was a retrospective cohort study of data collected from the West Yorkshire Trauma Network, comprising a major trauma centre, Leeds General Infirmary, and five peripheral trauma units. All patients aged 0-18 years who required trauma unit management during the school closure period (18 March 2020-25 May 2020) were included. Cases for the matched period in 2019 were analysed for baseline comparison. Patient demographics, mechanism and anatomical location of injury, management and follow-up were assessed. Results In the 2020 and 2019 cohorts, 286 and 575 injuries were observed, respectively. In the 2020 cohort, we observed a 50.3% (n=289) fall in paediatric trauma presentation and a significant proportional reduction in referrals from the emergency department (22% (n=63) versus 53% (n=305); p<0.001). There was also a significant reduction in the average age at presentation by more than one year (p<0.001). Sports-related injuries decreased significantly (n=16 (5.6%) versus n=127 (22.1%); p<0.001). While the proportion of ride-on injuries increased significantly, overall numbers remained similar (n=63 (22%) versus n=61 (10.6%); p<0.0001). Non-accidental injury (NAI) concerns rose significantly (n=9 (3.1%) versus n=4 (0.7%); p=0.01), but the absolute number of confirmed NAI cases stayed the same (n=2). There was a proportional increase in upper limb injuries (64.3% (n=184) versus 58.4% (n=336); p>0.05) and a proportional reduction in lower limb injuries (32.1% (n=92) versus 35.5% (n=204); p>0.05). However, the rate of tibial shaft injuries rose significantly (10.1% (n=29) versus 5.2% (n=30); p=0.02). The use of conservative management increased with a significant delay in average time to surgery from the date of injury (8.5 days versus 3.1 days; p=0.01). Patients who were only followed up with a telephone consultation rose significantly (23% (n= 66) versus 6% (n=35); p<0.001). Re-presentation rate increased significantly (1.4% (n=4) versus 0.2% (n=12); p=0.04). Conclusion Our study showed a reduction in paediatric trauma presentations during the pandemic and a significant reduction in the average age at presentation. This change has been accompanied by a shift in the mechanism and anatomical location of injury, management and subsequent follow-up.

A retrospective epidemiological cohort study of ankle fractures in children and teenagers

Background

Ankle fracture is one of the most frequent pediatric lower-limb fractures and may result in serious complications.

Objective

This study aimed to determine the epidemiology of ankle fractures, defining fracture types, treatments, and complications in a pediatric population below 16 years old.

Methods

Medical records of all the ankle fracture patients treated in our hospital during 2004-2020 were retrospectively reviewed. Data regarding age, sex, mechanism of injury, fracture type, treatment modalities, and complications were collected.

Results

We examined records involving 328 children with 331 ankle fractures, with a ratio of 1:2 male per female. Mean annual prevalence was 24.3 per 100,000 children. Mean patient age was 11.2 ± 4.2 years, with 75.3% of them aged over 10 years. Sports activities accounted for the largest percentage of fractures (162 cases; 49.4%), followed by falls (67; 20.4%) and road traffic accidents (37; 11.3%). Physeal fractures were the most frequent type of lesion (223 cases). Most ankle fractures (60%) were managed using closed reduction and casting; for the remaining 40% of cases, fracture fixation was performed after closed or open reduction to correct the articular step-off and ensure the anatomical restoration of the physis. The main ankle fracture complication was premature growth arrest (12.1% of all physeal fractures).

Conclusion

Pediatric ankle fractures primarily affect children older than 10 years. Most of these fractures were caused by sports injuries or low-energy trauma. The majority of these fractures are physeal, and the distal tibial physis is affected 10 times more frequently than the distal fibular physis.

Level of evidence

Level III.

Comparison of diagnostic performance of a deep learning algorithm, emergency physicians, junior radiologists and senior radiologists in the detection of appendicular fractures in children

BACKGROUND

Advances have been made in the use of artificial intelligence (AI) in the field of diagnostic imaging, particularly in the detection of fractures on conventional radiographs. Studies looking at the detection of fractures in the pediatric population are few. The anatomical variations and evolution according to the child's age require specific studies of this population. Failure to diagnose fractures early in children may lead to serious consequences for growth.

OBJECTIVE

To evaluate the performance of an AI algorithm based on deep neural networks toward detecting traumatic appendicular fractures in a pediatric population. To compare sensitivity, specificity, positive predictive value and negative predictive value of different readers and the AI algorithm.

MATERIALS AND METHODS

This retrospective study conducted on 878 patients younger than 18 years of age evaluated conventional radiographs obtained after recent non-life-threatening trauma. All radiographs of the shoulder, arm, elbow, forearm, wrist, hand, leg, knee, ankle and foot were evaluated. The diagnostic performance of a consensus of radiology experts in pediatric imaging (reference standard) was compared with those of pediatric radiologists, emergency physicians, senior residents and junior residents. The predictions made by the AI algorithm and the annotations made by the different physicians were compared.

RESULTS

The algorithm predicted 174 fractures out of 182, corresponding to a sensitivity of 95.6%, a specificity of 91.64% and a negative predictive value of 98.76%. The AI predictions were close to that of pediatric radiologists (sensitivity 98.35%) and that of senior residents (95.05%) and were above those of emergency physicians (81.87%) and junior residents (90.1%). The algorithm identified 3 (1.6%) fractures not initially seen by pediatric radiologists.

CONCLUSION

This study suggests that deep learning algorithms can be useful in improving the detection of fractures in children.

Descriptive Study on Epidemiology, Clinical Presentation, Treatment, and Outcome of Supracondylar Fractures Treated in a Base Hospital of Sri Lanka: A Single-Center Study

INTRODUCTION

Supracondylar fractures are common pediatric elbow injuries, with management in developing countries presenting challenges due to limited resources, inadequate facilities, and a lack of trained personnel.

METHOD

This study aimed to describe the incidence, demographics, clinical presentation, treatment methods, and outcomes of supracondylar fractures treated at Ashraff Memorial Hospital (AMH)-Kalmunai, a base hospital in Sri Lanka. This is a retrospective descriptive study conducted between January 2019 and December 2020.

RESULTS

The study involved 79 children with supracondylar fractures. The majority of the children were male (70.9%) and their ages ranged from one to 15 years. The study identified falls as the most common presenting complaint (92.4%), followed by road traffic accidents (3.8%), native treatment (2.5%), and mismanagement (1.3%). The majority of fractures affected the right side (69.6%), while the remaining cases involved the left side (30.4%). Regarding the time duration from fracture to hospital presentation, a significant proportion of children sought medical attention on the same day (51.9%), followed by presentations within the first three days (38%), within a week (5.1%), or after a month (3.8%). Based on the Gartland classification, type I fractures accounted for 44.3% of cases, followed by type II fractures (29.1%) and type III fractures (26.6%). The most common treatment approach was closed reduction and percutaneous pinning (41.8%). Other treatment options included plaster of Paris (POP) cast without manipulation (36.7%), POP cast with manipulation (7.6%), analgesics alone (6.3%), and open reduction fixation (5.1%). Follow-up procedures varied, with routine cast removal (11.4%), routine cast and K-wire removal (45.6%), and re-do surgery with routine follow-up (1.3%). Among the type III fractures, two children presented with vascular compromise and anterior interosseous nerve (AIN) impairment, while another two children had AIN impairment only. Type I and type II fractures did not exhibit nerve involvement or vascular impairment. Only one out of the 79 children had an open fracture.

CONCLUSION

Supracondylar fracture is the most common orthopedic fracture in children. The study sheds light on the challenges and opportunities associated with treating pediatric supracondylar fractures in a resource-constrained context. The findings can help produce guidelines for the management of supracondylar fractures in underdeveloped nations, as well as contribute to global efforts to enhance the management of pediatric fractures.

Is There an Association between BMI, Height, and Gender and Long-Bone Fractures during Childhood and Adolescence? A Large Cross-Sectional Population Study of 911,206 Subjects

INTRODUCTION

Traumatic long-bone fractures (TLFs) among children and adolescents are relatively common, with morbidity and economic consequences. Obesity has become a significant global concern. Studies have found an association between TLFs and BMI in the past but not in a large cross-sectional population study. Our study objective was to measure the incidence of TLFs in the 17-year-old general population and evaluate its association with BMI, body height, and gender.

METHODS

Data from a medical database containing all 17-year-old candidates' records before recruitment into mandatory military service were retrieved as BMI, height, gender, and history of TLFs. Logistic regression models assessed the association between BMI and height to TLFs.

RESULTS

The records of 911,206 subjects (515,339 males) were reviewed. In total, 9.65% had a history of TLFs (12.25% and 6.25% for males/females, respectively). Higher BMI was associated with TLF, with a linear trend in the odds ratio (OR) for having TLFs. The strongest association was found between obese females and TLFs (OR = 1.364, p < 0.0001). Height was an independent factor positively associated with TLFs. The OR for a TLF in the highest height quintile was 1.238 (p < 0.001) for males and 1.411 (p < 0.001) for females compared to the lowest quintile. Although TLFs were more common in males, the OR for TLFs was more prominent in females.

CONCLUSIONS

There is an association between BMI, body height, and TLFs in healthy adolescents. TLFs are more common in males, but the strongest association between overweight and obesity is evident in females.

Predictors for operative treatment in pediatric proximal third both-bone diaphyseal forearm fractures in children include age and translation, but not initial angulation

Introduction

Proximal third diaphyseal fractures of the radius and ulna represent an onerous fracture pattern due to difficulty maintaining acceptable alignment with nonoperative management. Our aim was to identify the factors that increase the odds for a surgical treatment of these fractures. Recognizing these factors can raise awareness to patients who are more likely to require additional care and assist clinicians in counseling families, targeting treatment plans, and constructing follow-up protocols. We hypothesized that the age of the patient, the amount of initial fracture displacement, and the angulation of the fracture would predict the need for operative treatment.

Methods

We retrospectively reviewed 276 proximal third diaphyseal forearm fractures at a single tertiary care institution. All patients underwent a nonoperative treatment trial, and if failed continued to surgery. Following a univariate analysis, we constructed a binary multivariate logistic regression model that included age, initial translation, and initial angulation to assess the association between the tested variables.

Results

A regression model revealed that age (10 years and older, odds ratio: 8.2, 95% confidence interval: 3.9-17.24, p < 0.001) and radius translation of more than 100% (odds ratio: 7.06, 95% confidence interval: 2.69-18.52, p < 0.001) were associated with the need for surgical treatment. Initial fracture angulation lacked an association with a surgical treatment (odds ratio: 0.81 95% confidence interval: 0.38-1.74, p = 0.59).

Conclusion

Age above 10 years and 100% initial translation of the radius fracture increased the odds for an ultimate decision to perform a surgery. Initial angulation, although often being the most remarkable radiographic feature, was not associated with a nonoperative treatment failure. We recommend an initial reduction attempt after counseling patients and their families that there is a high rate of conversion to operative treatment when the above features are met.

Level of evidence

level III.

Evaluation of overgrowth in pediatric radius fractures

PURPOSE

Forearm fractures are the most frequent long bone fractures in children. There have been many reports of differences in leg length due to overgrowth in lower extremity fractures. However, reports of such overgrowth in fractures of the upper extremity are rare. The purpose of this study was to investigate the relationship between angulation and overgrowth in pediatric radius fractures. We hypothesized that more angular deformation of the fracture would result in a periosteal transection and more overgrowth.

METHODS

Retrospectively, between 2013 and 2022, 14 patients under 16 years of age (mean age 9.43 years; 10 boys, four girls) with unilateral radius shaft or metaphyseal fracture without physeal injury, and a minimum follow-up of 12 months, were included. Demographic factors were analyzed; age, sex, body mass index (BMI), right or left. We evaluated the radiologic parameters; ulnar variances, degree of angularity before intervention, fracture gap and treatment options. The patients underwent conservative or surgical treatment.

RESULTS

The mean follow-up period was 27.9 months (range, 13-53 months). Eight patients underwent cast treatment, and six patients underwent surgical treatment. The difference in ulnar variances between the unaffected side and fracture side were statistically significant (P < 0.001). Sex, age, left or right, height, weight, and BMI were not statistically significant. The surgical treatment group (P = 0.013) and the sum of the maximum angularity (P = 0.017) were statistically significant. When the sum of the maximum angularity(SMA) was 30° or more, the ulnar variances were statistically significant, compared with the case where the SMA was less than 30°. The clinical results evaluated at the last outpatient follow-up were good in all patients.

CONCLUSIONS

First, this study implies that the degree of angulation of the fracture may affect the overgrowth of the radius in case of radius shaft or metaphyseal fracture, without physeal injury. Second, it implies that the degree of overgrowth may increase with surgical treatment, as opposed to that with conservative treatment.

LEVEL OF EVIDENCE

Level IV, Retrospective study.

Ultrasound assistance in treatment with elastic stable intramedullary nail fixation in radial and ulnar fractures in children

PURPOSE

Radial and ulnar fractures are one of the most common fractures in children. When closed reduction of fractures fails, elastic stable intramedullary nail (ESIN) fixation can mostly be used under the guidance of fluoroscopy. In this study, we evaluated the effect of ultrasound (US) as assistance for radial and ulnar fracture reduction and the insertion of ESINs.

METHODS

There were 56 patients with midshaft radial and ulnar fractures included in our hospital from March 2019 to August 2021. After applying the inclusion and exclusion criteria and according to the treatment method, they were divided into the US group (patients treated with US assistance) and the conventional group (C-group, patients treated with fluoroscopy guidance). All patients' clinical data were collected. Operation time, fluoroscopy times, radiation dose, and post-operative complications were analyzed. The elbow function was evaluated using the Mayo Elbow Performance Index.

RESULTS

There were 26 patients in the US group and 30 in the C-group. The average operation time was 44.5±19.4 min in the US group and 65.1±16.2 min in the C-group. There were significant differences regarding the surgery time, fluoroscopy time, and radiation dose between the groups (all p = 0.001). The average follow-up time was 13.5±3.1 months. No significant difference was found regarding radial nerve injury, extensor pollicis longus rupture, non-union or delayed union, ulnar nerve injury, or acute compartment syndrome. There was no difference in elbow function at the final follow-up.

CONCLUSION

US guidance can be adopted for the treatment of displaced radial and ulnar fracture reduction and the insertion of ESINs. It can significantly decrease fluoroscopy times, radiation doses, and duration of surgery.

Analysis of the factors affecting pain level during K-wire removal among pediatric elbow fractures

Our aim was, to analyze the reasons for possible increased pain during the removal of the Kirschner wires from the elbows of children. From February 2021 to December 2021, 573 patients with elbow fractures were treated. In total, 150 patients were analyzed prospectively. No action was taken to reduce pain during the removal of Kirschner wires. The pain status of the patients was evaluated according to the Wong-Baker FACES Pain Rating scoring system (WBAS), the Numeric Rating Scale (NRS) for the pain system and the pulse and oxygen saturation measured by the pulse oximeter on the finger. Measurements were performed before, during, immediately after and 30 min after the procedure. There were 119 patients with a diagnosis of supracondylar humerus fracture and 31 patients with a diagnosis of lateral condyle fracture. The mean age of treated patients was 7.1 years (1-15 years). Of the patients, 93 were boys and 57 were girls. In the measurements made according to the sex difference, it was determined that there was a statistically significant increase in the WBAS scores measured both before the procedure ( P  = 0.032) and during the removal ( P  = 0.017), and also in the pulse measurements taken 30 min after the removal in girls ( P  = 0.034). A statistically significant difference was found in both the WBAS score during removal ( P  = 0.025) and the NRS scores 30 min later ( P  = 0.048) in the procedures performed on the right elbow. We found a statistically significant increase in the pain parameters we evaluated in girls, right extremity fractures, the group over 8 years old and when both parents were with the child during the K-wire removal procedure. In light of these findings, physicians should consider the above-mentioned conditions before starting the procedure to ensure a less painful and positive experience.

The Ulnar Olecranon-Coronoid Notch Angle Affects Terminal Elbow Extension in Children and Adolescents

BACKGROUND

Limitations to terminal elbow extension (TEE) in pediatric populations have been commonly associated with the degree of ligamentous laxity and not bony factors. Ligamentous laxity, quantified through the Beighton score, is criticized for unreliably assessing joint mobility. This study aims to show that the olecranon-coronoid notch angle (OCNA) affects TEE in healthy children and adolescents.

METHODS

A retrospective study of 711 pediatric patients treated for upper extremity and shoulder injuries was cross-sectionally studied at 2 tertiary centers from 2014 to 2021. Radiographs were used to measure the OCNA, humerocondylar angle, proximal anterior ulnar angle, and the presence of secondary centers of ossification. A 2-axis goniometer measured clinical TEE to a firm endpoint. The statistical analysis studied the relationships between OCNA and TEE and the effect that age and sex have on these measurements.

RESULTS

Increased TEE was associated with increased OCNA (P<0.001) when accounting for age and sex. The average OCNA was 30.0 degrees (7.5 degrees), and the average TEE was 5.6 degrees (8.0 degrees). There was a difference in OCNA between subjects who had elbow hypoextension, normal TEE, and elbow hyperextension (P<0.001). The most common injuries were distal radius fractures (182, 26%), elbow sprains and contusions (111, 16%), distal both bone forearm fractures (95, 14%), single or both bone shaft fractures (77, 11%), and supracondylar fractures (74, 11%).

CONCLUSION

These results show that the orientation of the opening of the olecranon-coronoid notch influences the arc of TEE motion in a healthy pediatric population. The notch restrains TEE by activating the bony block mechanism between the olecranon apophysis and the olecranon fossa. The measurement of the OCNA can serve as a reproducible and quantitative method to predict hypomobility to hypermobility of TEE motion.

LEVEL OF EVIDENCE

Prognostic study: Level II.

Impact of Pediatric Orthopaedic Fellowship Training on Pediatric Supracondylar Humerus Fracture Treatment and Outcomes: A Meta-analysis

BACKGROUND

Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI.

RESULTS

This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury.

CONCLUSIONS

Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients.

LEVEL OF EVIDENCE

Level III; Meta-analysis.

Pediatric Open Long-Bone Fracture and Subsequent Deep Infection Risk: The Importance of Early Hospital Care

The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula (p = 0.022), higher revised Gustilo-Anderson type (p = 0.017), and a longer duration of time between the injury and hospital presentation (p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements (p = 0.022) and a total number of operative procedures (p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003-1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.

Incidence, characteristics, and treatments of traumatic open fractures in children and adolescents: A retrospective observational study

We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-affiliated hospitals, among which 206 patients (8.5%) presented with open fractures. The patients' clinical and radiographic records were reviewed, and the age, gender, cause of injury, injury season, injury week, associated injuries and complications were collected. This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2 ± 5.0 years. The patients were divided into an open fracture group (OF group, n = 206) and a group with no open fracture (No-OF group, n = 2212). There were 206 patients (8.5%) who presented with open fractures and the most common fracture sites were the tibia (31.1%, 64/206) and fibula (20.9%, 43/206). The patients in the OF group presented with higher frequency of emergency admission (P < 0.001), self-supporting medical insurance (P < 0.001), MVCs (P < 0.001), wounded by machine (P < 0.001), struck by object (P < 0.001), hurt/cut by others (P < 0.001), lower limb fractures (P < 0.001), multiple fractures (P = 0.010), associated injuries (P < 0.001) and wound infection (P = 0.003) then the patients in the No-OF group. The most common complication were wound infection (5.8%) and pneumonia (1.0%) in the OF group, wound infection (2.1%) and pressure sores (2.0%) in the No- OF group. Multivariate logistic regression analysis indicated that mechanical trauma (OR = 64.229, P < 0.001), being hurt/cut by others (OR = 26.757, P < 0.001), and being struck by an object (OR = 15.345, P < 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR = 5.970, P < 0.001), upper limb fractures (OR = 5.865, P < 0.001) and multiple fractures (OR = 5.414, P < 0.001) were stronger risk factors than craniofacial fractures for open fractures. The frequency of surgical treatment for the patients with traumatic open fractures (87.9%, 181/206) was significantly higher than those without open fractures (72.2%, 1596/2212) (P < 0.001). The hospital stays and fees for surgical treatment for the patients with traumatic open fractures were significantly higher than those without open fractures (P < 0.001). Etiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures and upper limb fractures) were independent risk factors for open fractures. Traumatic open fractures presented with higher surgical treatment rate, hospital stays and fees.

Epidemiology of pediatric fractures before versus during the coronavirus disease 2019 pandemic

Several studies have reported changes in the prevalence of childhood fractures between the prepandemic and coronavirus disease 2019 pandemic periods considering the overall decrease in activity during the latter. This review aimed to organize and summarize the global trends in pediatric fracture incidence. Our findings should help predict fracture patterns in the postpandemic period by identifying changes in the past and present, thus aiding patient management.

Gartland Type IIa Supracondylar Humerus Fractures: Outcomes of Attempted Nonoperative Management

BACKGROUND

The optimal treatment of Gartland type IIa supracondylar humerus fractures remains controversial. We report the results of a series of patients with type IIa fractures who underwent closed reduction and immobilization using conscious sedation in the emergency department. Our goal was to identify variables associated with fractures that were successfully managed nonoperatively.

METHODS

This was a retrospective cohort study of pediatric patients who underwent closed reduction of Gartland type IIa supracondylar humerus fractures with the use of conscious sedation in the emergency department. Prereduction and postreduction radiographs were reviewed to determine the degree of fracture extension, anterior humeral line index, Baumann angle, and splint flexion angle. The success of closed reduction was defined as a reduction that was maintained without the need for surgical intervention.

RESULTS

A total of 54 patients (54 elbows) were included in this study. The mean overall age was 5.2±2.5 years. Following the closed reduction in the emergency department, 38 (70%) patients were successfully managed nonoperatively with casting, and 16 (30%) patients required operative intervention. The degree of fracture extension on the injury radiograph was 13.2±8.4 degrees in the nonoperative group compared with 19.8±7.5 degrees in the operative group (P=0.008). The postreduction degree of fracture extension was 3.0±3.4 degrees in the nonoperative group and 10.0±7.2 degrees in the operative group (P<0.0001). The mean anterior humeral line index on the injury radiograph was 0.34 in the nonoperative group and 0.13 in the operative group (P=0.104). The mean anterior humeral line index on the postreduction radiograph was 1.2 in the nonoperative group and 0.38 in the operative group (P=0.0002). Patient age, prereduction and postreduction Baumann angle, and the postreduction splint flexion angle did not differ significantly between groups.

CONCLUSIONS

Closed reduction under conscious sedation in the emergency department is a viable treatment option for Gartland type IIa supracondylar humerus fractures. Increasing fracture extension on injury radiographs can help predict failure of nonoperative management following closed reduction.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Upper limb pediatric fractures in 22 tertiary children's hospitals, China: a multicenter epidemiological investigation and economic factor analysis of 32,832 hospitalized children

BACKGROUND

Fractures are the most common type of unintentional injury in children, with traumatic upper limb fractures accounting for approximately 80% of all childhood fractures. Many epidemiological investigations of upper limb fractures in children have been conducted, but with the development of society, the patterns of childhood fractures may have changed. This study aimed to analyze the epidemiology and economic cost factors of upper limb fractures in Chinese children.

METHODS

We retrospectively reviewed children with upper limb fractures or old upper limb fractures hospitalized between December 1, 2015, and December 31, 2019, in 22 tertiary children's hospitals, under China's Futang Research Center of Pediatric Development. We used the ICD10 codes on the front sheet of their medical records to identify cases and extracted data on age, sex, injury cause, fracture site, treatment, the year of admission and discharge, visiting time, and various costs during hospitalization from the medical record.

RESULTS

A total of 32,439 children (21,478 boys and 10,961 girls) were identified, of whom 32,080 had fresh fractures and 359 had old fractures. The peak age was 3-6 years in both sexes. A total of 4788 were infants, 14,320 were preschoolers, 10,499 were in of primary school age, and 2832 were adolescent. Fractures were most frequent in autumn (August to October). Admissions peaked at 0 o'clock. Among the 32,080 children with fresh upper limb fractures, the most common fracture site was the distal humerus, with a total of 20,090 fracture events including 13,134 humeral supracondylar fractures and 4914 lateral humeral condyle fractures. The most common cause of injuries was falling over. The most common joint dislocation accompanying upper limb fractures occurred in the elbow, involving 254 cases. Surgery was performed in 31,274 children, and 806 did not receive surgery. Among those with clear operative records, 10,962 children were treated with open reduction and 18,066 with closed reduction. The number of cases was largest in the East China region (Anhui Province, Shandong Province, Jiangsu Province, Zhejiang Province, and Fujian Province), with 12,065 cases overall. Among the 359 children with old fractures, 118 were admitted with a diagnosis of "old humerus fracture," accounting for the highest proportion; 244 underwent surgical open reduction, 16.16% of whom had osteotomy. For the children with fresh fractures, the average total hospital cost was 10,994 yuan, and the highest average total hospital cost was 14,053 yuan, for humeral shaft fractures. For the children with old fractures, the average total hospital cost was 15,151 yuan, and the highest average total hospital cost was 20,698 yuan, for old ulna fractures. Cost of materials was the principle factor affecting total hospital cost, followed by surgery and anesthesia costs, both in children with fresh fractures and those with old fractures. Significant differences were observed in all hospital costs (P < 0.001) except treatment costs (P = 0.702), between children with fresh fractures and those with old fractures. Among the 32,439 children, full self-payment accounted for the highest proportion of all payment methods, involving 17,088 cases, with an average cost of 11,111 yuan.

CONCLUSION

Information on the epidemiological characteristics of childhood fractures suggests that health and safety education and protective measures should be strengthened to prevent upper limb fractures in children. For both fresh and old fractures, the cost of materials was the principal factor affecting total hospital cost, followed by surgery and anesthesia costs. The overall average total hospital cost is higher in children with old fractures than in children with fresh fractures. Among all children, full self-payment, at 53% of children, accounted for the highest proportion of all payment methods. Hospital costs are a headache for those families who will pay on their own. It can lead to a delayed treatment and unhealed fractures or malunion in some children. Therefore, the child trauma care system and training on fractures need to be improved, to reduce the late presentation of fractures. These combined measures will improve children's quality of life, reduce the expenditure of families, and decrease the public health burden. To provide better medical services for children, authorities must improve the allocation of health resources, establish a comprehensive medical security system for children, and set up more child trauma centers.

Is modified reverse step-cut osteotomy better than Yun's reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial

BACKGROUND

Various corrective osteotomy techniques have been described in the literature for correcting paediatric cubitus varus. But we are still in search of the perfect technique that gives maximum possible deformity correction and cosmetic appearance that satisfies parents with minimal complications. We compared the outcomes of two technically sound osteotomy techniques having minimal postoperative lateral condyle prominence described in the literature.

RESEARCH QUESTION

Is modified reverse step-cut osteotomy (MRSO) better in terms of clinical, radiological, and cosmetic outcomes than Yun's reverse V osteotomy (RVO) in pediatric cubitus varus deformity correction?

METHODS

In total, 20 children with unilateral cubitus varus resulting from malunited supracondylar humerus fractures were included. Randomization was done by computer-generated random slips. A total of ten cases each were operated by MRSO and RVO techniques, respectively. Clinical, radiological, and cosmetic appearance assessments were done at the final two year follow-up and compared between the two groups.

RESULTS

The mean age of children in the MRSO and RVO groups is 9.9 years (3-16) and 8.6 years (3-16), respectively. The mean pre-operative carrying angle in the deformed elbow of MRSO and RVO group was - 20.5° and - 19.5°, respectively, and the mean pos-toperative carrying angle in the corrected elbow of MRSO and RVO group was + 6.8° and + 6.5°, respectively. Regarding the lateral prominence index (LPI), a positive correlation was noted between pre-operative and post-operative periods with a value of 0.855 and 0.844 (p value: 0.001 and 0.03, respectively) in both MRSO and RVO groups, respectively. However, the change was statistically not significant when compared between the two groups (p = 0.63). There was no statistically significant difference (p > 0.05) when the clinical, radiological, and cosmetic outcomes were compared between the groups at final follow-up.

CONCLUSION

The surgeon can choose either one of these techniques based on their expertise since the results of both the techniques are comparable in terms of clinical, radiological, and cosmetic outcomes.

Testing a new method of osteosynthesis of forearm fractures in children; a prospective randomized controlled longitudinal study

PURPOSE

Displaced children's forearms fractures are commonly treated surgically with Kirschner Wires or Elastic Stable Intramedullary Nails. The osteosynthesis system "Minimally Invasive Reduction and Osteosynthesis System" might be beneficial in the treatment of these fractures due to being minimally invasive while achieving fracture stability. In this exploratory prospective randomized controlled longitudinal study, we compared Minimally Invasive Reduction and Osteosynthesis System to Kirschner Wires and Elastic Stable Intramedullary Nails osteosynthesis.

METHODS

Twenty children were included consecutively to treatment with either conventional surgery (5 Kirschner Wires/5 Elastic Stable Intramedullary Nails) or Minimally Invasive Reduction and Osteosynthesis System (10). Evaluation of radiographic alignment and clinically of range of motion, pain status, grip strength, level of physical activity and scar size were compared after 3 months and after 5 years.

RESULTS

Surgical parameters of the duration of insertion- and removal-surgery, the need for postoperative casting and scar size were significantly better for Minimally Invasive Reduction and Osteosynthesis System. All osteosynthesis systems maintained radiographically fracture alignment at three months and 5 years follow-up. Clinical status regarding pain, grip strength difference, and return to recreational activities were not significantly different. The complication rates were nonsignificant, but MIROS had moderate severe complications of refractures, while mild complications occurred when operated on with Kirschner Wires/Elastic Stable Intramedullary Nails. Our study was sufficiently powered at 3 months, but the comparisons are suggestive at 5 years.

CONCLUSION

In conclusion, Minimally Invasive Reduction and Osteosynthesis System is not significantly different to other surgical methods in radiological outcomes for forearm fractures in children. Minimally Invasive Reduction and Osteosynthesis System has the clinical benefit of omitting casting after surgery, obtaining reduced scar size, and shorter insertion and removal time without general anesthesia. However, moderately severe complications occurred.

LEVEL OF EVIDENCE

Level II-a prospective comparative study.

Epidemiology and management of 10,486 pediatric fractures in Shenzhen: experience and lessons to be learnt

Purpose

To explore and analyze the causes and related influencing factors of pediatric fractures, and provide theoretical basis for reducing the incidence and adverse effects of pediatric fractures.

Methods

This study retrospectively analyzed the epidemiological characteristics of fractures in pediatric aged ≤18 years old who were admitted to the our hospital between July 2015 and February 2020.

Results

A total of 10,486 pediatric patients were included in the study, of whom 6961 (66.38%) were boys, and 3525 (33.62%) were girls. For the fracture incidence, age group of the 3-6 years reached the peak. 5584 (60.76%) children were operated upon within 12 h after admission. The top three types of fractures were the distal humerus (3843 sites, 27.49%), distal ulna (1740 sites, 12.44%), and distal radius (1587 sites, 11.35%). The top three causes of injury were falls (7106 cases, 82.10%), car accidents (650 cases, 65.72%), and clipping (465 cases, 5.37%). Fractures predominantly occurred between July and November (4664 cases, 48.87%) and on Saturdays and Sundays (3172 cases, 33.24%). The highest number of hospital visits occurred between 20:00 and 00:00 (4339 cases, 45.46%).

Conclusion

For pediatric fractures, we should take appropriate and effective preventive measures to reduce the incidence of children’s fractures according to the distribution characteristics of age, gender, cause of injury, and fracture site.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03199-0.

Comparative Effectiveness of Closed Reduction With Percutaneous Pinning and Open Reduction With Internal Fixation in the Operative Management of Pediatric Type III Supracondylar Fractures

Background

Supracondylar fracture with total displacement is classified as Gartland type 3. The operative management for this type of fracture can be closed reduction with percutaneous pinning (CRPP) or open reduction with internal fixation (ORIF). This study aims to determine whether CRPP or ORIF led to smaller changes in Baumann’s angle, the carrying angle, loss of motion, and complication when treating pediatric supracondylar fractures.

Methodology

In a retrospective cohort design, pediatric patients presenting with supracondylar fractures at a tertiary care hospital in Bahrain between March and October of 2021 were enrolled. The collected data included age, gender, nationality, mechanism of injury, neurovascular status, type of surgery performed, follow-up period, range of motion, complications, Baumann’s angle, carrying angle, and loss of motion. The changes in Baumann’s angle, carrying angle, and reduction sufficiency were compared to the literature using Flynn’s criteria for supracondylar fractures.

Results

This study included the records of 60 patients with supracondylar fractures. In total, 28 patients underwent CRPP (group A), whereas 32 underwent ORIF (group B). A statistically significant difference (p = 0.037) between group A and group B was noted when combining the loss of carrying angle scores and the loss of motion scores to form the final Flynn score. In group A, 26 (92.8%) cases had satisfactory results; 75% of these cases were excellent or good. According to Flynn’s criteria, all patients in group B were satisfactory; 93.75% of these cases were excellent or good. The loss of motion was significantly different between the two groups (p = 0.038). The mean loss of carrying angle was significantly different between the two groups, with 5.51 ± 3.03 degrees for group A and 4.23 ± 1.85 degrees for group B (p = 0.023). The study had only two cases with unsatisfactory ratings belonging to group A.

Conclusions

In pediatric patients presenting with type 3 supracondylar fractures, when compared to CRPP, ORIF was associated with less loss of motion, less loss of carrying angle, higher overall satisfactory results according to Flynn’s criteria, and fewer complications.

Functional Outcome of Closed Reduction and Extension Casting in Forearm Fractures in Children

Introduction

Fractures in children are extremely common scenarios encountered by orthopedicians. Conservative treatment has been the most preferred choice for the management of diaphyseal forearm fractures. Traditionally, pediatric forearm fractures are treated by above elbow plaster cast with the elbow flexed to 90 degrees. The purpose of this study was to evaluate the functional and radiological outcomes of children treated with closed reduction and extension casting for forearm fractures.

Patient and methods

This is a prospective study evaluating the functional and radiological outcomes of 30 children of less than the age of 14 years and without pathological fractures, treated with closed reduction and extension casting for forearm fractures, either both radius and ulna or radius or ulna at middle third level, who reported to the Department of Orthopedics, Dr. D.Y. Patil Medical College, Hospital, and Research Center, Pune, India, between September 2019 and March 2022.

Results

The mean pre-operative angulation in radius (antero-posterior {AP}) was 22.7, radius (lateral {LAT}) was 24.2, ulna (AP) was 31.2, and ulna (LAT) was 29.2. The immediate post-operative angulation of radius (AP) was 0.7, radius (LAT) was 3.2, ulna (AP) was 0.6, and ulna (LAT) was 4.9. Cast status at two weeks, 83.3% had intact cast and 16.7% had loosened casts. Post removal, most patients had a good rotation of motion (ROM) at three and six weeks.

Conclusion

Casting with extended elbow is much better as compared to flexion casting in the hands of a trainee doctor. Furthermore, chances of loss of reduction are negligible in extension casting as compared to flexion casting.

Unicolumnar Pin Fixation of Type III Supracondylar Humeral Fractures Is Associated With Over 3 Times Higher Odds of Lost Reduction

OBJECTIVES

To compare the rate of lost reduction between 2 groups of non-age-segregated type III supracondylar humeral fracture patients: a unicolumnar versus bicolumnar fixation group.

DESIGN

Retrospective cohort study.

SETTING

Pediatric Academic Trauma Center.

PATIENTS

We identified 257 patients with type III supracondylar humerus fractures from surgical billing records over a 5-year period. There were 183 patients identified with bicolumnar fixation (71.2%) and 74 patients identified with unicolumnar fixation (28.8%).

INTERVENTION

Closed reduction percutaneous pinning of the distal humerus.

MAIN OUTCOME MEASURES

The primary outcome measure was difference in rate of lost reduction between patients with bicolumnar (lateral and medial column) and unicolumnar (lateral column only) fixation (Fig. 1). The reduction and fixation at the time of fluoroscopy was assessed using the Baumann angle, Gordon index, and anterior humeral line. Loss of reduction was assessed at time of healing, defined by a Baumann angle change ≥10 degrees and Gordon index of ≥50% (Fig. 2).

RESULTS

There were 183 patients with bicolumnar fixation and 74 patients with unicolumnar fixation included in the study (average age 5.8 years; range, 2-14 years). The rate of lost reduction in patients with bicolumnar fixation was 6.01% (11/183), whereas 17.57% (13/74) of patients with unicolumnar fixation experienced lost reduction. These rates were significantly different (P = 0.008) with a 3.3 times higher odds (95% confidence interval = 1.3-8.6) of lost reduction with unicolumnar fixation.

CONCLUSIONS

There is a statistically significant increase in the rate of supracondylar fracture loss of reduction for patients with unicolumnar fixation when compared with bicolumnar fixation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Learning Curve of Closed Reduction and Internal Fixation for Supracondylar Fractures of the Humerus in Children

BACKGROUND

This study aimed to identify the threshold for success in supracondylar humeral fracture surgery by describing the learning curve for beginners and exploring the relationship between the learning curve and the prognosis of supracondylar fractures of the humerus.

METHODS

Surgical information was collected of the first 100 humeral fractures treated by four pediatric orthopedic surgeons. The relationship between operation time, wire placement success rate, and surgical experience was determined using the restricted cubic strip (RCS). The inflection point in the curve and other risk factors that may affect fracture prognosis were collected and subjected to multiple logistic regression to clarify the relationship between the learning curve and prognosis of supracondylar fractures of the humerus. After the training, the four fresh surgeons were interviewed in the form of questionnaires to get feedback from the trainees.

RESULTS

A total of 400 supracondylar fractures of the humerus from four pediatric orthopedists were included in the study. On an RCS analysis, 65 surgical experiences were the inflection point of the learning curve. Before and after these 65 surgical experiences, there were significant differences in the patients' anatomical reduction (186 vs. 122, P < 0.001), conversion to incision (33 vs. 6, P = 0.008), and supervising physician guidance (28 vs. 2, P < 0.001). In the multiple logistic regression analysis, functional recovery after supracondylar fractures of the humerus was significantly associated with surgical experience, intraoperative conversion to incision, and post-operative infection. Four surgeons and a supervisor were interviewed. They believed that self-confidence establishment requires the experience accumulation of about 30 operations. The most critical surgical technique is the reduction of fractures.

CONCLUSIONS

Although the accumulated experience of 30 operations can establish the self-confidence of trainers, fresh surgeons must accumulate experience with 65 operations to master closed reduction and internal fixation for supracondylar fractures. Surgical experience significantly impacts the post-operative recovery of patients with fractures.

LEVEL OF EVIDENCE

Level III.

Obesity as a Predictor of Outcomes in Type III and Type IV Supracondylar Humerus Fractures

OBJECTIVES

To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures.

DESIGN

Retrospective multicenter.

SETTING

Two Level I pediatric hospitals.

PATIENTS

Patients (age <18 years) with operatively treated Gartland type III and type IV fractures 2010-2014.

INTERVENTION

Closed or open reduction and percutaneous pinning of supracondylar humerus fractures.

MAIN OUTCOME MEASURE

Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates.

RESULTS

Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation.

CONCLUSIONS

The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors That Drive Annual Variation in Pediatric Elbow Fracture Occurrence, Severity, and Resource Utilization

BACKGROUND

Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR).

METHODS

Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization.

RESULTS

Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures.

CONCLUSION

Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources.

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Single-stage Distal Radius Dome Osteotomy with Ulnar Diaphyseal Shortening and Distal Ulnar Epiphysiodesis in A Case of Manus Valgus Deformity Secondary to Post-Traumatic Physeal Growth Arrest - A Case Report

Introduction

Distal radius physeal growth arrest in children secondary to trauma is a rare complication. Various modalities of surgical treatment exist. Correction of severe deformity by a single-stage surgery is rare in current literature. We describe a case of surgically treated posttraumatic manus valgus deformity in an adolescent female with a satisfactory surgical outcome.

Case Report

A 13-year-old right-hand dominant girl presented to us with a painless, gradually progressive left wrist deformity for the past 3 years. She sustained a left wrist injury 3.5 years back for which she received native treatment. She was able to do most of her daily activities and cosmetic disability was her primary concern. She had a 20° fixed radial deviation deformity with further radial deviation up to 60°. Forearm rotation was from 70° supination to 60° pronation. Her pre-operative Mayo Modified Wrist Score was 25/10/10/25/70 (Pain/Satisfaction/Range of motion/Grip strength/Total). Radiologically, there was the obliteration of lateral distal radial physis with overgrowth of medial physis. Distal ulnar physeal overgrowth led to positive ulnar variance. Radiologically, the magnitude of deformity was 43° manus valgus (+24° radial inclination). We performed dome osteotomy at distal radius metaphysis with distal radius plating through modified Henry approach. Simultaneous ulnar diaphyseal shortening osteotomy with plate fixation was done through a dorsal approach and distal ulnar epiphysiodesis was done by physeal drilling to prevent future overgrowth. At 13 months follow-up, the wrist has clinically no deformity and radiologically 5° manus valgus (+24° radial inclination). Both the osteotomy sites have united and ulnar variance is restored. Now, her ulnar deviation was 20° and radial deviation was 30°. Her forearm rotational arc was maintained. Mayo Modified Wrist Score was 25/25/10/25/85 (Pain/Satisfaction/Range of motion/Grip strength/Total) with no hindrance of daily activity.

Conclusion

Correction of wrist deformity, restoration of ulnar variance, and normal wrist mechanics is possible in a single-stage surgery with judicious planning and can provide satisfactory result.

Hypodermic needle to guide Kirschner-wire placement in paediatric supracondylar humerus fractures: a technical trick

PURPOSE

Supracondylar humerus fractures are among the most common injuries in the paediatric population, accounting for 16% of all paediatric fractures and roughly 60% to 70% of all paediatric elbow fractures. Typical treatment for displaced and unstable supracondylar humerus fractures is surgical intervention, often with percutaneous Kirschner-wire (K-wire) fixation. Timing of surgery is dependent on the patient's neurovascular status on presentation, with surgical emergencies being performed at all hours of day and night. Percutaneous fixation of paediatric elbow fractures can be challenging as a result of the propensity for the elbow to become quite swollen with these fractures, particularly in smaller and physiologically more immature elbows.

METHODS

We have developed a simple operative technique to guide placement of percutaneous wires for supracondylar humerus fractures using a hypodermic needle as a reference marker.

RESULTS

In our experience, trainees utilizing this technique demonstrate greater appreciation for start point and trajectory of wires during percutaneous pinning, with better communication amongst surgical team members about necessary adjustment for optimal placement of K-wires.

CONCLUSION

Utilization of this technique has the potential to refine surgical technique by minimizing errant wire passes, radiation and operative time when performing percutaneous pinning of reduced type III supracondylar humerus fractures.

LEVEL OF EVIDENCE

V, Novel Surgical Technique.

Distal Radius Salter-Harris III Transitional Fracture in an Adolescent Male

In contrast to the well-described Tillaux fracture of the distal tibia, transitional fractures of the distal radius are exceedingly rare and have yet to be well described. Thus far, their presence in the literature has been limited to case reports and a singular series. None have involved a Salter-Harris III fracture pattern. We present the case of a 16-year-old male who sustained a Salter-Harris III transitional fracture of the distal radius with an associated ulnar styloid avulsion fracture secondary to a fall that was treated nonoperatively. Similar to the Tillaux fracture, examination of the distal radius transitional fracture should include computed tomography scan to better illustrate the pattern of injury and guide treatment.

A quality improvement initiative to reduce cast transitions in a pediatric hospital

A quality improvement protocol was implemented in a large tertiary care pediatric hospital to reduce the rate of transitions from emergency department (ED)-applied casts to another form of immobilization (waterproof cast, removable brace, or sling). The local standard of care prior to implementing this quality improvement project involved applying long-arm casts in the ED for children presenting with stable upper extremity injuries (those not requiring a reduction). We created a multidisciplinary quality improvement team with orthopedic and ED providers, as well as cast technicians, with the aim of reducing the transition rate of ED-applied casts in clinic by 50%. Multiple Plan-Do-Study-Act cycles were performed and data were evaluated monthly. Charge fees were determined to assess differences in costs between splints and casts. An independent samples t-test for equality of means was used to determine the ED length of stay of each group. Baseline data determined a cast transition rate of 59.9%. After implementing the quality improvement protocol, the cast transition rate was reduced to 25.0%, a 58% reduction. The length of stay in the ED for a patient receiving a splint as opposed to a cast was 26.2 ± 8.0 min shorter. The charge to a patient receiving a splint rather than an ED-applied cast was $291.25 less. In conclusion, implementation of a multidisciplinary quality improvement protocol resulted in a more than 50% reduction in the transition rate of ED-applied casts in the clinic. Furthermore, healthcare charges to families were reduced by nearly $130 000 annually after implementation of this protocol.

Management of Distal Radius Fractures in Adolescent Patients

BACKGROUND

While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population.

METHODS

A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized.

RESULTS

Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes.

CONCLUSIONS

Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Refracture Rate of Both Bone Forearm Fractures: A Retrospective Comparison of Casting Alone Versus Casting and Extended Functional Bracing

BACKGROUND

One of the most common pediatric fractures is a midshaft both bone forearm fracture. The preferred nonoperative treatment is cast immobilization for 6 to 8 weeks; however, 4% to 8% refracture within 6 months. There are no comparative studies evaluating the efficacy of bracing after cast immobilization. We hypothesized that children treated with prolonged functional bracing would have a lower rate of refracture than casting alone or short-term bracing.

METHODS

This is a retrospective review of children younger than 15 years of age treated nonoperatively following radius and ulnar shaft fractures treated at 3 tertiary pediatric hospitals. We excluded distal radius/ulna fractures, isolated fractures of the radius/ulna, and fractures near the elbow. Logistic regression analysis on casting plus functional bracing was run to determine if age, translation, or the number of days in brace were associated with refracture. The incidence of refracture was compared between groups.

RESULTS

A total of 1549 patients were screened and 426 were included in the study [111 casting only (CO), 259 casting plus functional brace <8 wk (CFB <8 wk), 56 casting plus functional brace ≥8 wk (CFB ≥8 wk)]. In comparing the groups, CO was the youngest (4.4 y vs. 6.3 and 8.4 y). The initial translation and angulation of the radius and ulna were significantly greater in the CFB ≥8 weeks group. Regression analyses shows no association between refracture and initial fracture characteristics including age, translation, or the number of days in brace. The CO group had 3 refractures (2.7%), the CFB <8 weeks group had 13 (5%) and the CFB ≥8 weeks group had 1 (1.8%); demonstrating no statistical significance.

CONCLUSION

Extended fracture bracing, following a period of cast immobilization, did not lead to a statistically significant difference in refracture rate. Contrary to previous cases series, the benefit of bracing seems nominal. Larger, prospective studies are needed to better understand targets for treatment.

LEVEL OF EVIDENCE

This is the first level III retrospective comparison study of its kind.

Custom-made polyurethane-based synthetic bones mimic screw cut-through of intramedullary nails in human long bones

Intramedullary nails are considered the gold standard for the treatment of tibial shaft fractures. Thereby, the screw-bone interface is considered the weakest link. For biomechanical evaluation of osteosyntheses synthetic bones are often used to overcome the disadvantages of human specimens. However, commercially available synthetic bones cannot adequately mimic the local mechanical properties of human bone. Thus, the aim of this study was to develop and evaluate novel cortical bone surrogate materials that mimic human tibial shafts in the screw-loosening mechanisms of intramedullary nails. Bone surrogates, based on two different polyurethanes, were developed and shaped as simple tubes with varying cortical thicknesses to simulate the diaphyseal cortex of human tibiae. Fresh frozen human tibiae and commercially available synthetic bones with similar cortical thickness were used as references. All specimens were treated with a nail dummy and bicortical locking screws to simulate treatment of a distal tibia shaft fracture. The nail-bone construct was loaded in a combined axial-torsional-sinusoidal loading protocol to simulate the physiological load during human gait. The loads to failure as well as the number of load cycles were evaluated. Furthermore, the cut-through length of the screws was analysed by additional micro computed -tomography images of the tested specimens. The failure load of custom made synthetic bone tubes with 6 mm cortical thickness (3242 ± 136 N) was in accordance with the failure load of human samples (3300 ± 307 N, p = 0.418) with a similar cortical thickness of 4.9 ± 1.4 mm. Commercially available synthetic bones with similar cortical thickness of 4.5 ± 0.7 mm were significantly stronger (4575 ± 795 N, p = 0.008). Oval-shaped migration patterns were "cut" into the cortices by the screws due to the cyclical loading. The cut-through length of the self-developed synthetic bones with 6 mm cortices (0.8 ± 0.6 mm, p = 0.516) matched the cut-through of the human tibiae (0.7 ± 0.6 mm). The cut-through of commercially available epoxy-based synthetic bones deviated from the human reference (0.2 ± 0.1 mm, p < 0.001). The results of this study indicate that the novel bone surrogates realistically mimic the failure and screw migration behaviour in human tibiae. Thus, they offer a new possibility to serve as substrate for biomechanical testing. The use of commercially available surrogates is discouraged for biomechanical testing as there is a risk of drawing incorrect conclusions.