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Tibial tubercle avulsion fractures (TTAF) often require surgical reduction and stabilization. Traditional teachings recommend postoperative knee immobilization for 4 to 6 weeks; however, the necessity of these restrictions is unclear and the actual practice varies. This study's purpose was to: (1) retrospectively review operatively managed TTAFs at a single center to examine the spectrum of postoperative rehabilitation guidelines, and (2) compare the outcomes of patients based on the timing of initiation of postoperative knee range of motion (ROM).Operatively managed TTAFs treated at a single center from 2011-2020 were identified. Patients with polytrauma, associated lower extremity compartment syndrome, or treatment other than screw fixation were excluded. Patient demographics, mechanism of injury, Ogden Classification, associated injuries, operative technique, postoperative ROM progression, and time to release to unrestricted activities were collected. Patients were grouped based on the initiation of postoperative ROM as Early (4 wk, EROM) or Late (≥4 wk, LROM). Bivariate analysis was used to compare characteristics between these 2 groups.Study criteria identified 134 patients, 93.3% (n=125) of whom were male. The mean age of the cohort was 14.77 years [95% confidence interval (CI: 14.5 to 15.0]. Forty-nine patients were designated EROM; 85 patients were categorized as LROM. The groups did not differ significantly with regards to age, race, injury characteristics, or surgical technique. Both groups progressed similarly with regards to postoperative range of motion. Ultimate activity clearance was achieved at ~20 weeks postoperatively without differences between groups ( P0.05). Four instances of postoperative complication were identified, all of which occurred in the LROM group.A broad range of postoperative immobilization protocols exists following the screw fixation of TTAFs. Across otherwise similar cohorts of patients undergoing operative treatment, initiation of knee range of motion before 4 weeks was without complication and provided equivalent outcomes to traditional immobilization practices. Given the clear benefits to patients and caregivers provided by the permission of early knee motion and the avoidance of casting, providers should consider more progressive postoperative rehab protocols following operatively treated TTAFs.Level III, Retrospective Cohort.

Resumen Introduccion Las fracturas de condilo humeral lateral (FCHL) representan del 12 al 17% de las fracturas de codo pediatrico. La asociacion de esta fractura con luxacion de codo es poco comun, siendo escasa la bibliografia y generalmente limitada a reportes de casos. Nuestro objetivo fue revisar sistematicamente la literatura sobre las fracturas del condilo lateral del humero asociadas a luxacion de codo en ninos. Metodos Se realizo una revision sistematica mediante una busqueda exhaustiva en las bases de datos PubMed y Embase de literatura revisada por pares entre 1960 y 2020. Dos revisores filtraron los resultados y buscaron articulos en ingles o espanol que reportan pacientes esqueleticamente inmaduros con fracturas del condilo lateral del humero asociadas a luxacion de codo. Los resultados analizados incluyeron caracteristicas del paciente y de la lesion, estrategias de tratamiento, complicaciones y resultados finales. Resultados La busqueda inicial arrojo un total de 851 estudios. Despues de la revision, se incluyeron 16 estudios, con 67 pacientes disponibles para revision. Las edades reportadas al momento de la lesion variaron entre 2 y 12 anos. La lesion se presento mas comunmente en varones con fracturas tipo Milch II, Jakob tipo 3. La direccion de la luxacion fue posteromedial en la mayoria de los casos. La reduccion abierta por abordaje lateral y la colocacion de clavijas Kirschner fue el tratamiento mas comunmente realizado. El seguimiento reportado se presento en un rango 3 a 156 meses. Catorce estudios informaron complicaciones en un tercio de los pacientes, que incluyen: limitacion del rango de movimiento, cubito varo, inestabilidad, prominencia del implante, retraso de la consolidacion, seudoartrosis, consolidacion viciosa, osificacion heterotopica, lesion neurologica y fallo del implante. Trece estudios informaron resultados clinicos, que se calificaron como regulares o pobres en 2 de cada 10 pacientes. Conclusiones La evidencia actual es nivel iv y sugiere que la tasa de complicaciones despues del manejo quirurgico de las fracturas de condilo lateral es elevada en el contexto de una luxacion de codo, lo que se asocia ademas a un alto porcentaje de resultados suboptimos. Las complicaciones mas frecuentes en esta serie fueron la rigidez articular y el cubito varo.

Femoral fractures are the most common cause of fracture-related admissions. Unplanned return to the operating room (UpROR) is a major event and imposes a substantial burden on the family and health care system. The purpose of this study was to determine the incidence of complications and early UpROR during the first 6 months following treatment of femoral fractures and their risk factors.In an institutional review board-approved study, a retrospective review of all patients who were treated for a femoral fracture during a 10-year period at a pediatric tertiary care center was performed. Patients less than 18 years old with a diaphyseal fracture and complete records were included, and nondiaphyseal or pathologic fractures, as well as underlying metabolic or genetic disorders, were excluded. All clinic visits in the first 6 months after treatment were reviewed, and all complications and UpRORs were extracted. Patients were grouped based on their age (below 5, 5 to 11, above 11 y old) at initial treatment, and statistical tests were used to infer differences between groups.Overall, 841 fractures in 832 patients were included, with a mean age of 5.5±4.8 years fracture, of which 72% were male. A total of 106 complications (12.6%) and 45 UpRORs (5.3%) were encountered during the study period. Patients with and without UpROR had similar demographics and injury and treatment characteristics. Loss of reduction was the most common reason for UpROR (58%), followed by implant-related complications. Flexible nails had the highest risk of UpROR among patients who were initially treated surgically (P=0.03).Our findings indicate that children under the age of 5 years have a 5% risk of UpROR in the first 6 months after the fracture, mainly for repeat spica casting due to loss of reduction. Patients aged 5 years or older have an ∼6% risk of UpROR, mainly related to complications of flexible nails. The findings of this study are important when consulting families on different treatments of diaphyseal femoral fractures.Therapeutic level III-retrospective cohort study.

OBJECTIVE To define the clinical importance of various pediatric musculoskeletal diagnoses, determine preferred communication methods based on the acuity level of findings, and investigate differences between specialties utilizing the Delphi methodology. METHODS Radiologists, orthopedic surgeons, and sports-medicine pediatricians at a tertiary children's hospital were surveyed (n = 79) twice using REDCap (Research Electronic Data Capture). Surveys were conducted anonymously and at least 1 year apart, first eliciting all potentially non-routine findings and various communication methods (round 1), and later categorizing the acuity (emergent, urgent, or non-urgent) of different diagnosis categories and selecting the preferred communication method (verbal, written electronic messages, and report) and timeframe (round 2). Chi-square, Fisher's exact, and Kruskal-Wallis H tests were used to compare variables between specialties. RESULTS Round 1 produced 267 entries for non-routine findings (grouped into 19 diagnoses) and 71 for communication methods (grouped into 3 categories). Round 2 found no significant difference in the acuity assignments for the 19 predetermined diagnoses (p = 0.66) between the 3 specialties; however, there was reduced agreement for the top urgent diagnoses within and between specialties. Most pediatricians preferred written electronic messages. The preferred communication timeframe for urgent diagnoses was significantly different (

While overall survival for children is greater than that for adults, synovial sarcoma remains an aggressive neoplasm with a potentially poor prognosis, and its magnetic resonance imaging (MRI) findings in children are not well described. We aimed to characterize the spectrum of MRI findings of synovial sarcoma in children with respect to anatomical location and outcome. Children with histologically confirmed synovial sarcoma and preoperative MRI performed within the past 11 years (2009–2020) were included. Two radiologists retrospectively reviewed each MRI to categorize location, signal characteristics and associated findings. Chi-square and Fisher exact tests were used to assess associations with locations and outcomes. This study included 23 children (13 girls, 10 boys; mean age: 12.7±4.2 years) with 7 axial, 8 proximal and 8 distal appendicular lesions. Kappa ranged from 0.53 to 1. MRI findings differed significantly between locations with axial lesions measuring larger (P=0.01) and more likely to contain fluid levels (P=0.02), triple sign (P=0.02), inhomogeneous signal (T1-weighted images, P=0.003; T2-weighted images, P=0.02, contrast-enhanced images, P=0.03) with all lesions containing partially solid composition (P=0.03). At a median follow-up of 14 months (interquartile range: 7–33 months), 39% relapsed. Predictors of relapse (P

Delayed diagnosis of scaphoid fractures can lead to long-term morbidity. While radiography is the preferred screening examination, there is a relative paucity of literature that examines fracture visibility in younger children, who have smaller ossification centers, an abundance of unossified cartilage and fractures that preferentially involve the distal scaphoid. To characterize acute scaphoid fractures in younger children on radiographs with observer agreement and with respect to fracture location. This institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant cross-sectional study included children (≤10 years of age) with acute scaphoid fractures (≤7 days), who underwent radiographic examinations at a tertiary children’s hospital between December 2008 and June 2019. Three readers (two pediatric radiologists and one orthopedic surgeon) reviewed each examination to determine fracture visibility on each radiographic view and fracture location. Kruskal-Wallis, Fisher exact and Cochran-Armitage tests were used to compare fracture visibility and location, and Kappa tests were used to calculate observer agreement. Twenty-eight children (15 boys, 13 girls; mean age: 9.5±0.6 years) with 10 (36%) distal corner, 11 (39%) distal body and 7 (25%) mid-body fractures, underwent 7 (25%) 4-view, 18 (64%) 3-view and 3 (11%) 2-view examinations. Twenty-six (93%) fractures were visible on at least one view with six (21%) fractures visible on all available views. No significant association was found between fracture visibility and fracture location (P=0.32). Observer agreement was substantial to almost perfect. Only 7% of these acute scaphoid fractures in younger children are inconspicuous on the initial radiographic examination.

Magnetic resonance imaging (MRI) plays a critical role in disease characterization of intra-articular tenosynovial giant cell tumor. To characterize the MRI features of intra-articular tenosynovial giant cell tumor in children with respect to disease subtype and anatomical location. This retrospective study included children with tenosynovial giant cell tumor who underwent preoperative MRI between January 2006 and May 2020. Two radiologists reviewed each examination to determine disease subtype, signal intensities and the presence of an effusion, osseous changes, chondromalacia, juxtacapsular disease and concomitant joint involvement. Fisher exact, Mann-Whitney U, and Kruskal-Wallis H tests were used to compare findings between subtypes and locations. Twenty-four children (16 girls, 8 boys; mean age: 13.1±3.8 years) with 19 knee and 5 ankle-hindfoot tenosynovial giant cell tumor had either diffuse (n=15) or localized (n=9) disease. An effusion (P=0.004) was significantly more common with diffuse than localized disease. There was no significant difference in MRI signal (P-range: 0.09–1) or other imaging findings (P-range: 0.12–0.67) between subtypes. Children with knee involvement were significantly more likely to present with diffuse disease while those with ankle-hindfoot involvement all presented with focal disease (P=0.004). Juxtacapsular (n=4) and concomitant proximal tibiofibular joint involvement (n=5) were observed with diffuse disease in the knee. Erosions (P=0.01) were significantly more common in the ankle than in the knee. In our study, diffuse tenosynovial giant cell tumor was more common than localized disease, particularly in the knee where juxtacapsular and concomitant proximal tibiofibular joint disease can occur.

Background Pediatric Orthopaedic Oncology is a developing subspecialty within the field of Pediatric Orthopaedics. Traditionally, the field of Orthopaedic Oncology has been focused on the skeletally mature individual, and the research tends to be all encompassing rather than truly evaluating isolated populations. The purpose of this review is to summarize the most clinically relevant literature in the field of Pediatric Orthopaedic Oncology over the last 6 years. Methods We evaluated the PubMed database utilizing keywords for pediatric orthopaedic oncology: sarcoma, osteosarcoma, Ewing sarcoma, bone cyst. In additionally, we further broadened our search by searching for relevant articles in the contents sections of major orthopaedic surgery journals that routinely publish both pediatric and orthopaedic oncology literature. In keeping with "What's New," we selected the most clinically relevant articles published in the last 6 years from January 1, 2014 through February 2020. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Results Our search yielded 60 articles that met general criteria, from which 14 were determined to be most relevant to the goals of this paper. Of the papers presented in this review, there were papers related to management of benign tumors/tumor-like conditions, bone cysts, limb salvage procedures, and amputation procedures. Ultimately included in the review were 5 studies related to limb salvage, 4 related to bone cysts, 1 related to multiple hereditary exostoses, 2 related to osteofibrous dysplasia, 1 related to chondroblastoma, and 1 discussing cementation in skeletally immature patients. They were level III, IV, and V studies. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search of the basic science and systemic therapies literature yielded 19 sources were found to be pertinent to our aims and 18 of those sources were published between 2015 and 2020. Conclusions There are many, varied, and creative procedures in the realm of limb salvage, though there remains a lack of high-level evidence to support some of the more novel procedures. In regards to benign bone tumors, despite a more solid base of literature, there still does not seem to be consensus as to the best treatment. In particular, there continue to be many schools of thought on the treatment of benign bone cysts. Research in the basic science arena and systemic therapies are advancing in exciting ways in regards to pediatric sarcoma. Orthopaedic oncologic research specific to the pediatric population overall continues to be impeded by low sample sizes and inadequate levels of evidence, which limits the ability of surgeons to draw definitive conclusions from the literature.

BACKGROUND Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures. METHODS We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed. RESULTS Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P

Purpose Distal radius fractures (DRFs) are common pediatric injuries typically treated with closed reduction and casting. A substantial number of these fractures fail nonsurgical management, occasionally requiring surgical intervention. Risk factors associated with an unsuccessful initial closed reduction (UIR) attempt or loss of reduction (LOR) after a successful closed reduction remain poorly characterized. Methods This was a retrospective investigation of pediatric patients with displaced DRFs treated by closed reduction and casting at a single children’s hospital from 2013 to 2017. Patient factors (age, sex, and body mass index) and radiographic measurements (fracture type, fracture displacement, associated ulna fracture, and cast index) were evaluated to determine risk factors for UIR and LOR. Results We identified 159 children (118 boys, mean age, 11 ± 3 years) with DRFs who underwent closed reduction and casting. An initial acceptable reduction was achieved in 81% of patients, and LOR occurred in 21.7%. Higher initial fracture translation in the sagittal or coronal plane and higher initial angulation in the coronal plane were associated with higher fluoroscopy times. Higher initial translation in the sagittal plane was independently associated with UIR. After closed reduction, residual translation in the sagittal plane and cast index were independent predictors for LOR. Fractures that were completely displaced in the sagittal plane were 6.2 times less likely to undergo an acceptable initial reduction, and fractures with any residual postreduction translation in the sagittal plane were 4.7 times more likely to demonstrate LOR. Conclusions The most important factors predicting failure of nonsurgical management of pediatric DRFs are translation in the sagittal plane and cast index greater than 0.80. To optimize patient outcomes, these variables should be recognized by the treating provider and emphasized during simulation training of orthopedic and plastic surgery residents. Type of study/level of evidence Prognostic III.

To systematically investigate age-dependent changes in scaphoid fracture prevalence and fracture patterns on radiographs in children under 15 years of age. This retrospective study included children with scaphoid fractures, who underwent radiographic examinations between May 1, 2009, and August 31, 2019. Blinded to outcome, all radiographs were reviewed to determine fracture visibility on initial radiographs; to characterize fracture location (distal corner, distal, mid, and proximal body) and orientation (horizontal oblique, transverse, and vertical oblique); and to identify the presence or absence of gap, displacement, and concomitant fractures. Demographic information and information on weight and height were collected. Mann-Whitney U, Kruskal-Wallis rank sum, chi-square, and post hoc tests were used to investigate associations between age, fracture characteristics, and BMI percentile. The study included 180 children (134 boys and 46 girls; 12.3 ± 1.4 years) with 59 (33%) distal corner, 42 (23%) distal, 76 (42%) mid, and 3 (2%) proximal body fractures. Younger children were more likely to present with distal corner and distal body fractures while older children with mid and proximal body fractures (p = 0.035). No association was found between age and fracture visibility (p = 0.246), fracture orientation (p = 0.752), presence of gap (p = 0.130), displacement (p = 0.403), or concomitant fractures (p = 0.588). Younger children with scaphoid fractures were more likely to be obese (n = 117; p = 0.038). Scaphoid fractures of the distal corner and distal body were significantly more common in younger children, who are more likely to be obese.

Osteosarcoma is the most common primary bone sarcoma in children. Imaging plays a pivotal role in diagnostic workup, surgical planning, and follow-up monitoring for possible disease relapse. Survival depends on multiple factors, including presence or absence of metastatic disease, chemotherapy response, and surgical margins. At diagnosis, radiography and anatomic MRI are used to characterize the primary site of disease, whereas chest CT and whole-body bone scintigraphy and/or PET are used to identify additional sites of disease. Treatment starts with neoadjuvant chemotherapy, followed by en bloc tumor resection and limb reconstruction, and finally, adjuvant chemotherapy. Preoperative planning requires precise tumor delineation, which traditionally has been based on high-spatial-resolution anatomic MRI to identify tumor margins (medullary and extraosseous), skip lesions, neurovascular involvement, and joint invasion. These findings direct the surgical approach and affect the options for reconstruction. For skeletally immature children, the risk of cumulative limb-length discrepancy and need for superior longevity of the reconstruction have led to the advent and preferential use of several pediatric-specific surgical techniques, including rotationplasty, joint preservation surgery, autograft or allograft reconstruction, and extendible endoprostheses. A better understanding of the clinically impactful imaging features can directly and positively influence patient care.

Dynamic supination is a well-recognized cause of congenital clubfoot deformity relapse. However, there is no consensus on how to diagnose it and there are varied approaches in its management. This study aims to define dynamic supination and indications for treatment by presenting consensus from an international panel of experts using a modified Delphi panel approach.An international panel of 15 pediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements using a 4-point Likert scale on dynamic supination, clinical indications for treatment, operative techniques, and postoperative casting and bracing. All panelists participated in 2 voting rounds with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70% to 79%), and indeterminate (69% or less).Consensus was achieved for 34 of 51 statements. Panelists agreed dynamic supination is present when the forefoot is supinated during swing phase of gait with initial contact on the lateral border of the foot. There was also agreement that dynamic supination results from muscle imbalance between the tibialis anterior and the peroneus longus and brevis. There was no consensus on observation of hindfoot varus in dynamic supination, operative indications for posterior release of the ankle joint, or incisional approach for tibialis anterior tendon transfer. Reference to the calcaneopedal unit concept, planes of movement, and phases of gait were deemed important factors for consideration when evaluating dynamic supination.Consensus statements from the Delphi panel can guide diagnosis and treatment of dynamic supination in clubfoot deformity relapse, including clinical decision making regarding preoperative casting, surgical approach, and postoperative immobilization. Near-consensus and indeterminate statements may be used to direct future areas of investigation.Level V.

Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures.This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P0.01 considered significant.One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient.There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center.This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Background In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. Methods Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. Results A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1–17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60–100%). Mean follow-up was 5.17 years (2–12 years). Conclusion This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Distal femur physeal fractures are known to have a high incidence of complications. Our previous reported experience (pre-2007) showed a 40% complication risk, which prompted changes in our approach. The purpose of this study was to evaluate and compare the complication rate and outcome after implementation of these changes. This is a retrospective study of children with distal femur physeal fractures treated at a level 1 pediatric trauma center between 2007 and 2016. Patient demographics, fracture patterns, treatment and outcomes including complications and its risk factors were recorded and analyzed. We compared current results with our previously reported multicenter cohort (n = 73). Patients were male in majority (57/70) with a mean age of 13 ± 4 years. Fractures were most commonly Salter-Harris Type 2 (49/70) and displaced (59/70) on presentation, although neither characteristic was associated with complications. Most patients (63/70) were treated surgically, and the overall complication incidence was 36% (25/70), including growth arrest in 20 patients. The pre-2007 cohort was statistically significantly younger (P < 0.001) and was more commonly treated nonoperatively (P < 0.001). However, there was no statistically significant difference in complication incidence between studies (36% versus 40%, respectively, P = 0.751). Despite a lower threshold for surgery for distal femur physeal fractures in the past decade, the complication rate is still high and unchanged at 40%, and presenting patients are older. There were no new prognostic factors that showed statistically significant association with subsequent complications; however, patients with high-energy injury mechanisms and greater fracture displacements did have higher complication rates. These results demonstrate the inherent high complication risk for these injuries. Level of Evidence: III.

The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management).A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded.In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group.There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures.Level III.

Purpose In recent years, “servitization” has been studied extensively; however, as studies of the impact of servitization on firm performance offer mixed results, the conditions under which the relationship between servitization and performance becomes more significant are contested in the literature. These mixed results have led to the term “service paradox.” The paper aims to discuss these issues. Design/methodology/approach This study investigates servitization in the assembly industry based on a multi-country survey covering 539 industry plants in 22 countries. Findings The study contributes to the research on servitization by adding a contextual perspective to this relationship, taking into account level of development of the country in which a firm is located. Besides confirming the correlation between the servitization and performance, our study unveils a counter-intuitive result: a medium level of development of the country in which a firm is based corresponds to a stronger relationship between servitization and firm performance, whereas higher levels of development seem to diminish the increase in performance. Social implications This study balances out the focus in servitization on advanced economies and help to unveil its benefits in developing countries. Fostering servitization in developing economies can lead to social impact resulting from job shifts from manufacturing to service and the correlated implications for workers’ training and higher motivation experienced in service-based jobs. Originality/value Our study unpacks the “service paradox” and indicates that industry plants in developing countries can still harness the benefits of being first-movers, whereas, in developed countries, servitization may have become an order qualifier rather than a factor of differentiation.

BACKGROUND Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. METHODS We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. RESULTS We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

To define the clinical importance of various pediatric musculoskeletal diagnoses, determine preferred communication methods based on the acuity level of findings, and investigate differences between specialties utilizing the Delphi methodology.Radiologists, orthopedic surgeons, and sports-medicine pediatricians at a tertiary children's hospital were surveyed (n = 79) twice using REDCap (Research Electronic Data Capture). Surveys were conducted anonymously and at least 1 year apart, first eliciting all potentially non-routine findings and various communication methods (round 1), and later categorizing the acuity (emergent, urgent, or non-urgent) of different diagnosis categories and selecting the preferred communication method (verbal, written electronic messages, and report) and timeframe (round 2). Chi-square, Fisher's exact, and Kruskal-Wallis H tests were used to compare variables between specialties.Round 1 produced 267 entries for non-routine findings (grouped into 19 diagnoses) and 71 for communication methods (grouped into 3 categories). Round 2 found no significant difference in the acuity assignments for the 19 predetermined diagnoses (p = 0.66) between the 3 specialties; however, there was reduced agreement for the top urgent diagnoses within and between specialties. Most pediatricians preferred written electronic messages. The preferred communication timeframe for urgent diagnoses was significantly different ( 2 h for pediatricians, 4 h for radiologists, and 8 h for surgeons; p = 0.003) between specialties whereas no difference was found for emergent (p = 1) and non-urgent diagnoses (p = 0.80).Acuity assignment for the 19 pediatric-specific musculoskeletal diagnoses was not significantly different between specialties, but the preferred communication timeframe for urgent diagnoses was significantly different, ranging between 2 and 8 h.

Case Here, we present the case of a pediatric polytrauma patient found to have lower extremity intra-arterial fat embolism causing ischemic necrosis and ultimately necessitating below-the-knee amputation. Conclusion Fat embolism, a common complication of long bone fractures in adults, can be associated with significant morbidity. Although rare, it should be considered among the possible etiologies for a pulseless limb after trauma. Early fracture stabilization may prevent fat embolism and fat embolism syndrome; however, there is no known definitive treatment, and management is supportive.

BACKGROUND Nonossifying fibroma (NOF) is a common benign lesion in children and adolescents. This study investigated the risk of pathologic fracture in NOF lesions of the distal tibial based on anatomic location, clinical symptomatology, and imaging features, in order to propose an algorithm for the management of such lesions. METHODS In an IRB-approved retrospective case-control study, all patients diagnosed with NOF between 2010 and 2017 were extracted from our database. Patients below 18 years of age at the time of diagnosis and with lesions involving the distal tibia were included. Demographic data, the reason for visit, and the mechanism of injury were recorded. Radiographs were reviewed to record the size (absolute and relative to bone width) and location of each lesion. Computed tomography and magnetic resonance imaging examinations were also reviewed when available. Two authors graded all lesions using the Ritschl classification and determined the presence of 2 novel signs: the syndesmosis sign and the Pac-Man sign. RESULTS A total of 84 patients were included in the final analysis, of which 25 were in the fracture group and 59 in the nonfracture group. None of the patients in the fracture group was previously diagnosed with NOF, but nine (36%) patients had symptoms for >6 months preceding the fracture. Ankle sprain was the most common reason for visit in the nonfracture group. The lateral location of the lesion in the distal tibia (P=0.001), size (P

Background The treatment of acute pediatric Monteggia injuries involving a complete fracture of the ulna remains controversial. The purpose of this study is to compare the outcomes of immediate operative fixation to a trial of closed reduction and casting of acute pediatric Monteggia fractures involving complete ulna fractures. Methods We performed a retrospective analysis of 73 patients with Monteggia injuries with complete ulna fractures presenting to 2 pediatric trauma centers from 2008 to 2018. Patients were divided in 2 groups based on the treatment received: patients in group 1 (n=37, 51%) received surgical treatment; patients in group 2 (n=36, 49%) received a trial of closed reduction and casting. The mean follow-up of 15.2 weeks (range, 4.1 to 159 wk). The incidence of radiocapitellar joint redislocation, need for further intervention, complications, and recovery of range of motion was compared between the groups. Results There were no significant differences between groups 1 and 2 with regards to age (6 vs. 5.8 y, P=0.69), sex (54% vs. 47% female, P=0.64), or the mean maximal ulnar angulation (23 vs. 19 degrees, P=0.94). There was a higher proportion of proximal ulna fractures in group 1 versus 2 (62% vs. 33%, respectively, P=0.02). Bado type III and IV fractures were associated with operative management [odds ratio=22 (95% confidence interval: 1.68-288.7) and 14.9 (95% confidence interval: 2.09-106), respectively]. In group 2, 5 patients (13.9%) sustained a loss of radiocapitellar joint reduction following closed reduction and casting and ultimately received operative treatment. At final follow-up, there were no cases of recurrent radiocapitellar dislocation in either group, all patients achieved fracture union and regained full elbow range of motion. Conclusions Even in the presence of a complete ulna fracture, a trial of nonoperative management of acute pediatric Monteggia fractures with closed reduction and casting can result in comparable outcomes to those obtained with immediate surgical management. The nonoperative management of Monteggia fractures requires close clinical follow-up to ensure no loss of reduction. Level of evidence Level IV-therapeutic studies, case series.

Unicameral bone cyst (UBC) is a benign cystic lesion, most commonly diagnosed in the proximal aspects of the humerus and femur of growing children. Medullary venous obstruction is the leading pathogenesis theory, resulting in fluid accumulation, bone resorption, and cortical thinning. Most UBCs are asymptomatic and likely go undiagnosed, while the most common presentation is a pathologic fracture, either complete or insufficiency/stress. Younger children tend to present with active lesions, which are uniloculated, abut the physis, and have a higher recurrence or persistence rate after treatment. Lesions in older children tend to migrate away from the growth plate (latent), and might become multiloculated, especially if they recur after treatment. Radiographs are often diagnostic and reveal a centrally-located, lucent metaphyseal lesion with cortical thinning, although advanced imaging is also helpful is some cases. Most UBCs do not need treatment and are amenable to observation alone. Management ranges from aspiration and steroid injection to decompression, curettage, grafting, and internal fixation. Percutaneous or open surgical approaches are acceptable, and often yield good results, although high recurrence rates should be expected, especially in younger children with active lesions.

CASE We describe a case of a 9-year-old boy who presented with a left calf mass consistent with alveolar rhabdomyosarcoma involving the Achilles tendon. The patient underwent radical resection of the Achilles tendon and Achilles tendon allograft reconstruction. At 2.5-year follow-up, the child had full ankle range of motion and strength and no signs of disease. CONCLUSIONS Radical resection of Achilles tendon in the setting of malignancy and reconstruction with allograft is a rare procedure that has not been previously described in the pediatric population. Orthopaedic oncologists can consider this option for the rare malignancies involving the Achilles tendon.

While overall survival for children is greater than that for adults, synovial sarcoma remains an aggressive neoplasm with a potentially poor prognosis, and its magnetic resonance imaging (MRI) findings in children are not well described.We aimed to characterize the spectrum of MRI findings of synovial sarcoma in children with respect to anatomical location and outcome.Children with histologically confirmed synovial sarcoma and preoperative MRI performed within the past 11 years (2009-2020) were included. Two radiologists retrospectively reviewed each MRI to categorize location, signal characteristics and associated findings. Chi-square and Fisher exact tests were used to assess associations with locations and outcomes.This study included 23 children (13 girls, 10 boys; mean age: 12.7±4.2 years) with 7 axial, 8 proximal and 8 distal appendicular lesions. Kappa ranged from 0.53 to 1. MRI findings differed significantly between locations with axial lesions measuring larger (P=0.01) and more likely to contain fluid levels (P=0.02), triple sign (P=0.02), inhomogeneous signal (T1-weighted images, P=0.003; T2-weighted images, P=0.02, contrast-enhanced images, P=0.03) with all lesions containing partially solid composition (P=0.03). At a median follow-up of 14 months (interquartile range: 7-33 months), 39% relapsed. Predictors of relapse (P0.05) included metastasis at presentation, larger lesions, axial lesions and MRI findings of fluid level, T1-weighted hyperintensity, inhomogeneous signal (T1- and T2-weighted images) and poorly circumscribed margins.A significant association was found between location and MRI findings in our cohort of children with synovial sarcoma. Axial lesions were more likely to be larger, appear heterogeneous and be associated with a worse outcome.

BACKGROUND Operative treatment of medial epicondyle fractures can be performed in either a supine or prone position. In the supine position, fracture visualization is sometimes difficult due to the posterior position of the medial epicondyle. However, the prone position requires extensive patient repositioning but may improve visualization. The purpose of this study was to compare the results and complications between the supine and prone position when treating medial epicondyle fractures. METHODS In a retrospective chart review, patients below 18 who underwent open reduction and internal fixation of an acute medial epicondyle fracture from January 2011 to August 2019 were identified. Patients with

Case A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques. Conclusions In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component.

Lateral humeral condyle fractures are the second most common fracture around the elbow in children. However, the association of an elbow dislocation is a rare entity. Therefore, literature on young patients with this uncommon combination is sparse. We aimed to perform a systematic review of the literature searching for pediatric lateral condyle humerus fractures associated to elbow dislocation.A systematic review of the PubMed and Embase databases was conducted for peer-reviewed literature between 1960 and 2020. Two reviewers filtered the results, looking for articles in English and Spanish that reported fractures of the lateral condyle of the humerus associated to elbow dislocation in skeletally immature patients. Outcomes included patient and injury characteristics, treatment strategies, complications, and final outcomes including range of motion.The initial search yielded a total of 851 studies. After initial screening, 16 studies were included, with 67 patients available for review. Age reported at the time of injury ranged from 2 to 12 years. The lesion occurred more commonly in males (60%) with Milch II, and Jakob type 3 fractures. The direction of the dislocation was posteromedial in most cases. Open reduction by lateral approach and Kirschner pin placement was the most performed treatment. The reported follow-up ranged from 3 to 156 months. Fourteen studies reported complications in 1/3 of the patients including: limited range of motion, cubitus varus, instability, hardware prominence, delayed union, nonunion, malunion, heterotopic ossification, neurological injury, and hardware failure. Thirteen studies reported clinical outcomes, which were rated as fair or poor in 2out of 10patients.Current evidence is level IV and suggests that the complication rate after surgical management of lateral condyle fractures is substantial in the context of an associated elbow dislocation, with an elevated percentage of suboptimal results. The most frequent complications in this series were elbow stiffness and cubitus varus.

Bone and soft-tissue tumors are common in the pediatric population. It is important to be familiar with the appropriate workup, principles of biopsy, differences between unicameral and aneurysmal bone cysts, and principles of managing pathologic fractures in children. The management approach to pediatric soft-tissue masses and some of the recent advances in the field warrant discussion.

A triplane fracture is an example of a transitional fracture of adolescence that occurs because the distal tibial physis closes in a predictably asymmetric way from central to medial and then lateral. The triplane fracture is so named because the fracture lines propagate in 3 planes (axial, sagittal, and coronal) and thus appear on radiographs as a Salter-Harris III pattern on anteroposterior images and Salter-Harris II or IV on lateral images. The fracture occurs via a twisting mechanism (usually supination and external rotation) through the relatively weak open portion of the physis (axial) and propagates out the metaphysis (coronal) and/or epiphysis (sagittal) at the transition to the relatively stronger closed portion of the physis. Because the distal tibial physis closes over approximately an 18-month period in female patients from 12 to 14 years old and male patients from 13 to 15 years old, this is the age range in which triplane fractures occur. Triplane fractures account for approximately 5% to 10% of pediatric ankle fractures. The purpose of the present video article is to review the indications for operative treatment of transitional ankle fractures in adolescents and to detail the surgical technique specifically for open reduction and screw fixation of triplane fractures. The procedure is performed in order to provide anatomic reduction of the fracture and rigid fixation. DESCRIPTION: Surgical treatment of a triplane fracture is indicated if there is >2 mm articular displacement of the distal aspect of the tibia or if the fracture pattern is deemed unstable following closed reduction and casting. Preoperative planning (Step 1) involves the use of radiographs and computed tomography scans to determine accurate fracture classification, the intended reduction maneuver, possible blocks to reduction, and screw trajectory and length. Room setup and patient positioning (Step 2) include placing the patient in the supine position with a bump under the hip, as well as the placement of a ramp or stack of blankets under the affected limb and adequate general anesthesia with muscle relaxation to facilitate reduction. Incision and surgical exposure (Step 3) is performed with use of an anterior ankle incision at the anatomic plane between the extensor hallucis longus and extensor digitorum longus, protecting the neurovascular bundle (i.e., the anterior tibial artery and deep peroneal nerve). Open reduction and assessment of reduction (Step 4) begins by removing any soft tissue, such as the periosteum, that may be interposed in the fracture site precluding a reduction. The ankle is then put through internal rotation and dorsiflexion in order to reduce the fracture, utilizing direct visualization through the incision and fluoroscopy to verify reduction with 2 mm articular displacement or >3 mm physeal displacement of the distal aspect of the tibia. Achieving and maintaining reduction with screw fixation within these tolerances helps decrease the chance of arthritis development by 5 to 13 years postoperatively(5,7). EXPECTED OUTCOMES: Following treatment of a triplane fracture with reduction and screw fixation, full ankle range of motion and normal growth are anticipated. Postoperative follow-up continues until skeletal maturity or until 1 year postoperatively with evidence of continued growth by Park-Harris lines on sequential radiographs. Short-term recovery is expected to be excellent, and long-term results are expected to be good as long as

Interstitial mycosis fungoides (IMF) is a rare variant of mycosis fungoides, a cutaneous T-cell non-Hodgkin’s lymphoma. It is characterized by an interstitial dermal infiltrate of lymphocytes and histiocytes between collagen bundles. We report the case of a 54-year-old patient with pruritic hypochromic macules on the arms and forearms diagnosed with IMF. Special attention was given to the anatomopathological features that differentiate this entity from its differential diagnoses, such as inflammatory morphea, interstitial annular granuloma, and other variants of the mycosis fungoides itself. We also present a review of the literature on the classification of the IMF.

Antalgic gait is a common clinical presentation among pediatric patients and can have many different etiologies, with rare life-threatening etiologies including primary bone malignancies. Osteosarcoma is the most common primary malignancy of bone in pediatric and adolescent patients. The incidence rate of osteosarcoma has been reported as high as 5 to 7 per million among patients 19 years old or younger with males slightly more affected than females and African-Americans more than other racial groups. This report describes the case of a five-year-old African-American female who presented with an antalgic gait secondary to osteosarcoma in the left distal femur and follows her through treatment. In this case, the age is atypical as the peak incidence for osteosarcoma is around 16 years of age and is postulated to coincide with growth spurts. Osteosarcoma can have a range of presentations making it difficult to diagnose, which can cause delays in treatment and potential poor patient outcomes. Due to this, such a diagnosis must be included in the differential for patients presenting with antalgic gait. Because primary-care physicians and pediatricians may be the first medical providers to encounter patients with osteosarcoma, it is imperative that such clinicians are familiar with the signs and symptoms associated with osteosarcomas in order to reduce the risk of metastasis and disease progression and prevent treatment delays. Additionally, we believe these clinicians should have a low threshold to refer patients to orthopedists or oncologic specialists in the cases of persistent pain or inconsistencies with history, physical exam, and diagnostic studies. Finally, direct communication and discussion between radiologists and referring clinicians helps decrease delays in diagnosing of osteosarcoma and other life-threatening conditions.

Interstitial mycosis fungoides (IMF) is a rare variant of mycosis fungoides, a cutaneous T-cell non-Hodgkin’s lymphoma. It is characterized by an interstitial dermal infiltrate of lymphocytes and histiocytes between collagen bundles. We report the case of a 54-year-old patient with pruritic hypochromic macules on the arms and forearms diagnosed with IMF. Special attention was given to the anatomopathological features that differentiate this entity from its differential diagnoses, such as inflammatory morphea, interstitial annular granuloma, and other variants of the mycosis fungoides itself. We also present a review of the literature on the classification of the IMF. RESUMEN La micosis fungoide intersticial (MFI) es una variante poco común de la micosis fungoide, un linfoma cutáneo de células T no Hodgkin. Se caracteriza por un infiltrado dérmico intersticial de linfocitos e histiocitos entre haces de colágeno. Presentamos el caso de un paciente de 54 años con máculas hipocrómicas pruriginosas en brazos y antebrazos diagnosticado de MFI. Se prestó especial atención a las características anatomopatológicas que diferencian a esta entidad de sus diagnósticos diferenciales, como morfea inflamatoria, granuloma anular intersticial y otras variantes de la propia micosis fungoide. También presentamos una revisión de la literatura sobre la clasificación de la MFI. RESUMO A micose fungoide intersticial (MFI) é uma variante rara da micose fungoide, um linfoma cutâneo de células T não Hodgkin. É caracterizada por um infiltrado dérmico intersticial de linfócitos e histiócitos entre feixes de colágeno. Relatamos o caso de um paciente de 54 anos com máculas hipocrômicas pruriginosas nos braços e antebraços com diagnóstico de MFI. Atenção especial foi dada às características anatomopatológicas que diferenciam essa entidade de seus diagnósticos diferenciais, como morfeia inflamatória, granuloma anular intersticial e outras variantes da própria micose fungoide. Apresentamos também uma revisão da literatura sobre a classificação da MFI.

Antalgic gait is a common clinical presentation among pediatric patients and can have many different etiologies, with rare life-threatening etiologies including primary bone malignancies. Osteosarcoma is the most common primary malignancy of bone in pediatric and adolescent patients. The incidence rate of osteosarcoma has been reported as high as 5 to 7 per million among patients 19 years old or younger with males slightly more affected than females and African-Americans more than other racial groups. This report describes the case of a five-year-old African-American female who presented with an antalgic gait secondary to osteosarcoma in the left distal femur and follows her through treatment. In this case, the age is atypical as the peak incidence for osteosarcoma is around 16 years of age and is postulated to coincide with growth spurts. Osteosarcoma can have a range of presentations making it difficult to diagnose, which can cause delays in treatment and potential poor patient outcomes. Due to this, such a diagnosis must be included in the differential for patients presenting with antalgic gait. Because primary-care physicians and pediatricians may be the first medical providers to encounter patients with osteosarcoma, it is imperative that such clinicians are familiar with the signs and symptoms associated with osteosarcomas in order to reduce the risk of metastasis and disease progression and prevent treatment delays. Additionally, we believe these clinicians should have a low threshold to refer patients to orthopedists or oncologic specialists in the cases of persistent pain or inconsistencies with history, physical exam, and diagnostic studies. Finally, direct communication and discussion between radiologists and referring clinicians helps decrease delays in diagnosing of osteosarcoma and other life-threatening conditions.

BACKGROUND: At many institutions, junior orthopaedic surgery residents perform the closed reduction and casting of pediatric distal radius fractures (DRFs). The purpose of this study was to evaluate the competency of junior residents compared to senior residents in the initial management of pediatric DRFs. METHODS: This investigation was a case-control study analyzing the outcomes of children with displaced DRFs treated by junior versus senior residents. The cohorts were matched with respect to fracture type. Radiographs were measured to assess fracture angulation, displacement, and cast index. Comparisons of patient characteristics, fracture characteristics, and outcome variables were made between the cohorts. RESULTS: A total of 132 patients (99 males; mean age 10.7±2.6 years) were included. Junior residents achieved a similar rate of acceptable initial reduction compared to senior residents (82% versus 79%; p=0.66). Twenty-four (23%) patients were found to have loss of reduction (LOR), though the rate of LOR was similar in the junior (16.7%) and senior resident (28.9%) cohorts (p=0.13). Overall, only 6 patients (3.7%) required surgery (1.5% in junior versus 7.6% in senior; p=0.09). The odds of LOR were 2.7 times higher in the first three reductions of the rotation for all residents (p=0.049). CONCLUSION: Junior residents perform similarly to senior residents in the closed reduction and casting of pediatric DRFs. However, residents performing one of their first three closed reductions during a rotation—regardless of seniority—were more likely to experience subsequent loss of reduction, suggesting the need for close supervision during the beginning of each rotation. Level of Evidence: III

This tumor quiz represents an interactive session where POSNA members are able to work through 9 clinical scenarios to challenge how they would address these problems. Associated with each scenario is an OITE-style question and multiple choice options that seek the most preferred answer from the clinician. In addition to the answer and follow-up radiographs, we have enlisted the opinions of three POSNA experts in oncology to provide an evidenced-based approach to thinking through each tumor problem.

Delayed diagnosis of scaphoid fractures can lead to long-term morbidity. While radiography is the preferred screening examination, there is a relative paucity of literature that examines fracture visibility in younger children, who have smaller ossification centers, an abundance of unossified cartilage and fractures that preferentially involve the distal scaphoid.To characterize acute scaphoid fractures in younger children on radiographs with observer agreement and with respect to fracture location.This institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant cross-sectional study included children (≤10 years of age) with acute scaphoid fractures (≤7 days), who underwent radiographic examinations at a tertiary children's hospital between December 2008 and June 2019. Three readers (two pediatric radiologists and one orthopedic surgeon) reviewed each examination to determine fracture visibility on each radiographic view and fracture location. Kruskal-Wallis, Fisher exact and Cochran-Armitage tests were used to compare fracture visibility and location, and Kappa tests were used to calculate observer agreement.Twenty-eight children (15 boys, 13 girls; mean age: 9.5±0.6 years) with 10 (36%) distal corner, 11 (39%) distal body and 7 (25%) mid-body fractures, underwent 7 (25%) 4-view, 18 (64%) 3-view and 3 (11%) 2-view examinations. Twenty-six (93%) fractures were visible on at least one view with six (21%) fractures visible on all available views. No significant association was found between fracture visibility and fracture location (P=0.32). Observer agreement was substantial to almost perfect.Only 7% of these acute scaphoid fractures in younger children are inconspicuous on the initial radiographic examination.

Objective Aneurysmal bone cysts (ABC) are benign but locally aggressive lesions. Treating children with spinal ABC poses risks due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability after surgery. This study reports the updated outcomes of a uniform aggressive initial surgical technique for the treatment of spinal ABC in children. Methods Twenty-nine cases of spinal ABC were collected from a tertiary pediatric tumor center over a 24-year period (January 1990–September 2014). The study patients were divided into 2 groups based on the performed procedure: a traditional approach consisting of curettage and bone grafting (group 1) and a 4-step approach consisting of intralesional curettage, high-speed bur, electrocautery, and bone grafting (group 2). Results The study population was composed of 12 males and 17 females with a mean age of 12.2 years at the time of diagnosis and a mean postoperative follow-up of 4.03 years. Twenty-one patients underwent the 4-step approach, while 8 patients were treated with the traditional technique. The recurrence rate was 50% (4/8 patients) with the traditional technique (group 1) and 19% (4/21) in the 4-step technique (group 2) (P = .164). Regardless of the technique used, the presence of sensory symptoms at the time of presentation was a statistically significant factor for recurrence (P = .016). Conclusions We suggest that addressing spinal ABC in pediatric patients with a 4-step approach is a safe technique that may decrease long-term recurrence and reoperation rates compared to the traditional technique of intralesional curettage and bone grafting. Level of Evidence 4.

BACKGROUND: Bilateral femur fractures are rare in the pediatric population with few cases reported in the literature. The purpose of this study was to review our institutional experience with a case series of simultaneous bilateral femur fractures to highlight the presentation, treatment, and outcomes of these rare injuries as well as perform a preliminary comparison to similar unilateral femur fractures in order to identify any clinically relevant differences that may guide future management. METHODS: We undertook a retrospective chart review of patients who had presented with simultaneous bilateral femur fractures between 2007 and 2017 with a minimum of 1-year of follow-up. Descriptive information was provided about the case series of bilateral femur fracture patients with subsequent further analysis comparing unilateral and bilateral femur fractures. RESULTS: Eight patients (7 males, 1 female) were identified after chart review. Mean age at the time of injury was 11 years (8 to 15 years). Mechanism of injury was high energy trauma in 7 of 8 patients. Six of 8 patients presented with at least one significant associated injury. All patients underwent operative fixation bilaterally. Average length of stay was 12 days (range 4-27 days). Four patients required admission to inpatient rehab facility. Complete healing occurred in all patients. One patient experienced unilateral genu valgum deformity treated successfully with growth modulation. Another patient experienced a unilateral bony bar of approximately 20% of the physis which did not result in angular deformity or limb length discrepancy. After comparing to a matched unilateral femur fracture cohort, we found that patients who sustained bilateral femur fractures had a significantly higher number of associated injuries as well as greater length of stay (p