Epidemiologic Changes in Pediatric Fractures Presenting to Emergency Departments During the COVID-19 Pandemic

BACKGROUND

Fractures are a common pediatric injury. The coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes in daily life that could impact the incidence of pediatric fractures. The purpose of this study was to compare the incidence of pediatric fractures in the United States during the COVID-19 pandemic to previous seasonally adjusted fracture incidence rates using the National Electronic Injury Surveillance System (NEISS) database and the American Community Survey (ACS).

METHODS

The NEISS database was queried from 2016 to 2020 for fractures occurring in pediatric (0 to 17 y) patients. ACS population data allowed for the estimation of fracture incidence per 1000 person-years. Using a quasiexperimental interrupted time series design, Poisson regression models were constructed to test the overall and differential impact of COVID-19 on monthly fracture rate by age, sex, fracture site, injury location, and disposition.

RESULTS

Our sample consisted of 121,803 cases (mean age 9.6±4.6 y, 36.1% female) representing 2,959,421±372,337 fractures nationally. We identified a stable 27% decrease in fractures per month after February 2020 [risk difference (RD) per 1000 youth years=-2.3; 95% confidence interval: -2.98, -1.57]). We found significant effect modification by age, fracture site and injury location ( P <0.05). The fracture incidence among children 5 years or older significantly decreased, as well as the incidence of fractures at school [RD=-0.96 (-1.09, -0.84)] and during sports [risk difference=-1.55 (-1.77, -1.32)]. There was also a trend toward a reduction in upper extremity fractures and fractures requiring admission.

CONCLUSION

A nationally representative injury database demonstrated a 27% decline in monthly pediatric fractures during the COVID-19 pandemic that persisted into the latter half of 2020. These trends appeared most attributable to a reduction in fractures discharged home and upper extremity fractures among older children sustained at school and in sports. Our findings provide unique insight into the epidemiology of pediatric fractures and demonstrate a baseline need for musculoskeletal care among young children even in the setting of a national shutdown.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Reliability and Validity of an MRI-Based Knee Sagittal Alignment Measure in a Pediatric Cohort

BACKGROUND

Magnetic resonance imaging (MRI) sagittal alignment is a measure that has been described and validated in the adult population as a means of distinguishing normal knees from those with anterior cruciate ligament (ACL) injury, but this measure has not been formally assessed among pediatric patients. The purpose of this study was to (1) assess the reliability of this MRI-based measure in a pediatric cohort, and (2) validate its ability to distinguish between ACL and non-ACL-injured knees in this population.

METHODS

A consecutive series of knee MRI examinations performed at our center were reviewed to identify studies of pediatric patients (1) with ACL injury, and (2) without significant pathology. Patient age, sex, physeal status (open, closing, or closed), knee laterality, and magnet strength (1.5 or 3-Tesla) were collected. The sagittal alignment was measured in both medial and lateral tibiofemoral compartments using a previously described method. Mean anterior tibial translation was then calculated for each study. Inter-rater and intrarater reliability testing was performed on a subset of randomly-selected patients from each cohort by three raters by calculating intraclass correlation coefficients. Sagittal alignment measurements of all patients were then completed by a single author after reliability was confirmed. The medial and lateral compartment translation and mean anterior tibial translation measurements of normal and ACL-injured knees were compared.

RESULTS

Inclusion criteria were met by 131 studies: 86 from uninjured knees (normal cohort) and 45 knees with ACL injury (ACL cohort). Studies were performed at a mean age of 13.4 with a near equivalent sex distribution. Inter-rater and intrarater reliability were good to excellent for all measures for patients in both normal and ACL cohorts. Normal and ACL-injured knees demonstrated a significant difference in anterior tibial translation in all measured regions. The mean anterior tibia translation for ACL-injured knees was 2.01 mm (95% confidence interval: 1.03-2.98) versus -0.44 mm (95% confidence interval: -0.89-0.014).

CONCLUSION

This study identified good to excellent inter-rater and intrarater reliability of knee sagittal alignment measurements among pediatric patients. It also demonstrated a significant difference in medial compartment, lateral compartment, and mean tibial translation in patients with and without ACL injury, validating previous findings demonstrated in adult cohorts. These findings may be useful in assisting providers in the confirmation of suspected ACL injury and insufficiency and guide operative management in cases of clinical uncertainty.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Semirigid Fiberglass Casting for the Early Management of Clubfoot: A Single-Center Experience

Background

Semirigid fiberglass (SRF) is an alternative material to plaster of Paris (POP) for idiopathic clubfoot casting in the Ponseti method. The purpose of this study was to evaluate early clinical outcomes in a series of idiopathic clubfoot patients treated with SRF at a single institution and to compare these findings to historical norms with POP casting present in the literature.

Methods

A series of idiopathic clubfoot patients managed exclusively with SRF in the Ponseti method was identified. Treatment efficacy was evaluated by number of casts, change in Pirani score, frequency of treatment-related complications, and frequency of surgery other than tenotomy. A comprehensive literature review was used for comparative historical norms.

Results

The study included 34 feet in 26 patients. Pirani score was 4.7±1.3 at presentation and 1.9±1.4 at the end of casting, representing a score change of 2.8±1.3 with SRF. Initial correction was obtained with 6.9±1.4 casts. Treatment-related complications occurred in six treated feet (17.6%) including 13 cast slippages in five feet and one cast-related thigh abrasion. A total of 25 (73.5%) feet underwent tenotomy. Two feet required an additional surgical procedure.

Conclusion

Clubfoot patients treated with SRF demonstrated acceptable deformity correction following Ponseti-style casting. The quantitative clinical outcomes evaluated appeared similar to norms using POP present in the literature. The findings of this study support SRF as a viable alternative to plaster casting for clubfoot correction utilizing the Ponseti method. As such, further investigation for rigorous comparative assessment is warranted.

Postoperative Bracing on Pain, Disability, Complications, and Fusion Rate Following 1-3+ Level Lumbar Fusion in Degenerative Conditions: A Meta-Analysis

OBJECTIVES

Lumbar fusion surgeries in degenerative spinal conditions can be invasive and may challenge the normal biomechanical spine and joint function. Frequently, patients require postoperative rehabilitation management. The purpose of this meta-analysis is to determine if there is an advantage to using a postoperative lumbar orthosis with regard to postoperative function and surgical healing.

DATA SOURCES

Articles in the English language were searched in electronic databases including PubMed and Clinicaltrials.gov from January 1, 2004 to January 1, 2019.

STUDY SELECTION

Studies were included if they were described as being a prospective randomized trial, utilized a common pain score determinant, reported complications postoperatively, analyzed disability, and were published within a 15-year period. After review of 218 citations by 2 authors, 4 studies were identified as meeting the inclusion criteria.

DATA EXTRACTION

Pain scores (Visual Analogue Scale/Dallas Pain Questionnaire), disability (Oswestry Disability Index, Short Form-36, Roland-Morris Disability Questionnaire), postoperative complications and fusion rate outcomes were collected.

DATA SYNTHESIS

Four prospective randomized controlled trials were identified and met the inclusion criteria. The outcome disability level showed a combined effect differed from 0 and favored the control [g=0.26, 95% confidence interval (CI): 0.04-0.49, P=0.029]. Visual Analogue Scale pain's combined effect did not differ from 0 and did not favor either the control or brace group (g=0.01, 95% CI: -0.25 to 0.27, P=0.93). The odds ratio (ORs) for complication rates did not differ from 1 (OR=0.88, 95% CI: 0.47-1.65, P=0.69). There was no significant difference in the ORs for fusion rate. Study heterogeneity was measured for all outcomes and there was no excessive variation.

CONCLUSIONS

The present meta-analysis indicated no significant difference in pain scores, a decrease in disability level for control (no brace), no significant change in fusion rate, and no significant difference in the odds of complication for the brace group. These conclusions support the theory that there is no significant advantage of postoperative lumbar orthoses.