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Adequate pediatric pain management is difficult to achieve for a variety of reasons. Pain assessment is more difficult in the pediatric population. There are a variety of different tools that may be used to accurately assess pain. There are many modalities to achieve pain control, including pharmacologic and nonpharmacologic means. These different modalities should be used in unison to achieve pain control. Compartment syndrome is a surgical emergency, and pediatric patients present differently from adult patients. The 3 As (anxiety, agitation, increase in analgesia requirement) should be monitored in all pediatric patients.

Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confidence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accurately identify positive versus negative examination findings. Thiel-embalmed cadavers are a valuable resource for physical examination education. (Journal of Surgical Orthopaedic Advances 30(2):112-115, 2021).

In 2016, the American Academy of Pediatrics Section on Orthopaedics established an annual Musculoskeletal (MSK) Boot Camp course to fill the gaps in MSK knowledge, performance, and outcomes for pediatricians and primary care doctors. A standardized one-day curriculum of key MSK topics was developed including short lectures, hands-on workshops, debates, live webinars, and Q&A sessions. A survey was created to evaluate attendee confidence related to diagnosing 20 common MSK conditions in children and adolescents at the beginning and end of the course. Confidence in diagnosing the conditions was gauged using a 6-point Likert-type scale. A two-sample t test was used to compare overall confidence score pre- and post-seminar. In addition, each subtopic was analyzed. The average pre-seminar confidence score was 3.92 versus 4.86 post-seminar. All categories demonstrated a statistically increased confidence score post-seminar ( P < .0001). Live MSK continuing education for pediatricians is effective in improving confidence in clinical practice.

Back pain in the child or adolescent patient is one of the most common reasons for physician assessment and referral. Back pain prevalence in the teenage years has been purported in the literature as high as 35% (Joergensen et al., Eur J Pediatr 178:695–706, 2019). Although the majority of time it is musculoskeletal in nature and self-remitting, it still necessitates a thorough evaluation to rule out disorders that can result in significant disability, such as infection or tumor. Back pain itself should not be construed as a diagnosis, but rather a symptom of some underlying process. The physician should be able to take a thorough and detailed history to help direct for further diagnostic modalities as part of the workup. Activity modifications, exercises, rehabilitation, and management of emotional stressors can prevent recurrent episodes for most cases of musculoskeletal back pain. However, in cases of severe and persistent back pain, a thorough history combined with a detailed physical exam and appropriate imaging studies is necessary to determine if serious underlying pathology is to blame.

1. Alexa J. Karkenny, MD* 2. Brandon M. Tauberg, MD* 3. Norman Y. Otsuka, MD* 1. *Montefiore Medical Center and the Children’s Hospital at Montefiore, Bronx, NY * Abbreviations: AP: : anteroposterior LCPD: : Legg-Calve-Perthes disease MRI: : magnetic resonance imaging SCFE: : slipped capital femoral epiphysis 1. The differential diagnosis for a limping child or adolescent with hip or knee pain is broad. Delayed or missed diagnoses of slipped capital femoral epiphysis and Legg-Calve-Perthes disease have significant morbidity. Clinicians should understand when to suspect these disorders based on history, examination, and early imaging findings to allow for timely referral to a specialist. 2. Clinicians should also have a basic understanding of the treatment options and prognosis of these disorders to counsel patients and their families before and during treatment by a specialist. After completing this article, readers should be able to: 1. Identify the general anatomy relevant to slipped capital femoral epiphysis (SCFE) and Legg-Calve-Perthes disease (LCPD) pathology. 2. Recognize the symptoms and physical examination findings of SCFE and LCPD. 3. Know the basic laboratory values and imaging to order to evaluate for SCFE and LCPD when referring to a specialist. 4. Differentiate straightforward presentations of SCFE and LCPD. 5. Understand broad treatment categories and the prognoses of SCFE and LCPD. 6. Realize the importance of timely referral to a specialist for SCFE and LCPD. Pediatric hip pathology can lead to devastating complications, such as hip instability, early arthritis, and growth abnormalities. Two of the most common pathologies in this age group include slipped capital femoral epiphysis (SCFE) and Legg-Calve-Perthes disease (LCPD). The importance of early diagnosis is paramount in both of these disorders, to allow for early treatment and attempt to limit the potentially morbid outcomes. Because many of these children will initially present to their pediatrician, recognition and early referral to an orthopedic …

This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.

Purpose The morphology of the proximal femur has been extensively studied in the adult population. However, no literature providing a comprehensive evaluation of the anatomy in paediatric patients exists. The current study aims to characterize such anatomy in skeletally-immature patients, examine potential differences between genders, and analyze how these anatomical parameters change with age. Methods Cadaveric femurs from the Hamann-Todd Osteological Collection were examined. Specimens with open physes and no skeletal disease or deformity were included for analysis. Age and gender were recorded for each specimen. Each femur was photographed in standardized modified axial and anteroposterior views. In all, 14 proximal femoral anatomical parameters were measured from these photographs. Comparisons between genders and age were calculated. Results A total of 43 femurs from ages four to 17 years met inclusion criteria. The majority were female (56%); no difference existed in age between genders (p = 0.62). The specimens had a neutral mean neck-shaft angle (130.7º) and anteversion (12.8º), and the sphericity of the ossified femoral heads was symmetrical. Male specimens had significantly higher alpha angles (p = 0.01), posterior offset (p = 0.02), neck width (p = 0.04) and head-neck length ratio (p = 0.02) values than female specimens. Strong positive correlations exist between length/size parameters and age, while negligible correlations were noted for angular measurements. Conclusions This study establishes reference values for a comprehensive list of anatomical parameters for the skeletally-immature ossified proximal femur. It highlights gender differences in morphology and demonstrates that angular characteristics remain relatively stable while length parameters generally increase with age. Level of Evidence Level III Diagnostic

Purpose To evaluate sensitivity, specificity and accuracy of a radiographic slipped capital femoral epiphysis (SCFE)-diagnosis among medical specialists. Methods Three paediatricians, three paediatric radiologists and three paediatric orthopaedic surgeons completed two rounds of a survey of anteroposterior and frog-leg lateral radiographs of patients with a diagnosis of SCFE (25), femoroacetabular impingement (four), Legg-Calvé-Perthes (11) or no hip pathology (ten). Intra- and interobserver agreement among specialties regarding the diagnosis of a SCFE were assessed using Cohen's kappa coefficient (κ). Diagnostic accuracy of SCFE relative to the benchmark, a combination of the radiographic diagnosis based on Klein's line, clinical symptoms and surgical treatment, was assessed computing sensitivity, specificity and accuracy. Results Intraobserver agreement between the surveys was moderate among paediatricians (κ-range, 0.44 to 0.52), moderate to almost perfect among orthopaedic surgeons (κ-range, 0.79 to 0.88) and almost perfect among paediatric radiologists (κ-range, 0.83 to 1.00). Interobserver agreement for survey 1 and 2 was slight among paediatricians (mean κ, 0.19), substantial among orthopaedic surgeons (mean κ, 0.77) and almost perfect among paediatric radiologists (mean κ, 0.86). Sensitivity of SCFE-diagnosis was high among radiologists and orthopaedic surgeons (88% to 100% for both specialties), but lower for paediatricians (24% to 76%). Specificity was high among radiologists and orthopaedic surgeons (72% to 84%), however, variable among paediatricians (56% to 80%). Accuracy of a SCFE-diagnosis was highest in radiologists (84% to 92%), followed by orthopaedic surgeons (80% to 88%) and paediatricians (48% to 78%). Conclusion SCFE can be detected on radiographs by different medical specialties. Intra- and interobserver agreement, specificity, sensitivity and accuracy for radiographic SCFE-diagnosis amongst paediatric radiologists and orthopaedic surgeons are better than that of general paediatricians. Level of Evidence II

BACKGROUND Postoperative wound complications after posterior spinal fusion are difficult to manage. The incidence in the nonidiopathic patient population is significantly higher than the adolescent idiopathic population. A comparison of wound complications after posterior spinal fusion for nonidiopathic scoliosis between the utilization of the orthopaedic surgical team at the time of closure performing a nonstandardized wound closure versus a plastic surgeon with a plastic multilayered closure technique and rotational flap coverage when needed had not previously been evaluated. The purpose of this study was to compare the complication rate between nonstandardized and plastic multilayered closure of the surgical incision in patients undergoing posterior spinal fusion for nonidiopathic scoliosis. METHODS The charts of 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease and who underwent a posterior spinal fusion were reviewed. Forty-two patients had their incisions closed using the nonstandardized technique and 34 using the plastic multilayered technique. These 2 groups were compared for age, sex, primary diagnosis, number of levels fused, estimated blood loss, number of units transfused, operating room time, wound complication, and return to operating room. RESULTS The wound complication rate in the nonstandardized closure group was 19% (8/42) compared with 0% (0/34) in the plastic multilayered closure group (P=0.007). The unanticipated return to the operating room rate was 11.9% (5/42) for the nonstandardized closure patients versus 0% (0/34) for the plastic multilayered closure patients (P=0.061). CONCLUSIONS The use of the plastic multilayered closure technique in this patient population is important in an effort to decrease postoperative wound complications. The ability of the surgical team to decrease the infection rate of nonidiopathic scoliosis cannot be overstated. The method of wound closure plays a major role in lowering this incidence. LEVEL OF EVIDENCE Level III-therapeutic.

Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction.We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements.There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64).Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot.A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet.One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527).No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

Septic arthritis of the knee in the pediatric patient is a diagnosis that requires prompt identification and treatment. The purpose of this study was to identify clinical and laboratory parameters that allow differential diagnosis of septic arthritis from non-septic arthritis in children.Fifty-four pediatric patients with atraumatic isolated knee pain were retrospectively identified at three institutions and diagnosed with septic arthritis (SA, N = 28), Lyme arthritis (LA, N = 11), or transient synovitis (TS, N = 15). Clinical and laboratory data were analyzed to identify which factors were most predictive of SA of the knee.Fever at time of presentation, a negative anti-streptolysin-O (ASO), erythrocyte sedimentation rate (ESR)40 mm/hr, and C-reactive protein (CRP)20 mg/L were the most predictive factors for distinguishing between septic arthritis (SA) and non-septic arthritis (transient synovitis or Lyme arthritis). Elevated ESR and CRP were both significantly higher in patients with SA when compared to TS or LA.When evaluating children with atraumatic isolated knee pain, a combination of the above factors should be utilized when ruling out septic arthritis.

Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures.A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making.Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making.There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes.Level V.

Background Distal radius fractures are the most common injury in the pediatric population. The purpose of this study was to determine the variation among pediatric orthopaedic surgeons when diagnosing and treating distal radius fractures. Methods Nine pediatric orthopaedic surgeons reviewed 100 sets of wrist radiographs and were asked to describe the fracture, prescribe the type of treatment and length of immobilization, and determine the next follow-up visit. κ statistics were performed to assess the agreement with the chance agreement removed. Results Only fair agreement was present when diagnosing and classifying the distal radius fractures (κ=0.379). There was poor agreement regarding the type of treatment that would be recommended (κ=0.059). There was no agreement regarding the length of immobilization (κ=-0.004).Poor agreement was also present regarding when the first follow-up visit should occur (κ=0.088), whether or not new radiographs should be obtained at the first follow-up visit (κ=0.133), and if radiographs were necessary at the final follow-up visit (κ=0.163). Surgeons had fair agreement regarding stability of the fracture (κ=0.320).A subgroup analysis comparing various traits of the treatment immobilization showed providers only had a slight level of agreement on whether splint or cast immobilization should be used (κ=0.072). There was poor agreement regarding whether long-arm or short-arm immobilization should be prescribed (κ=-0.067).Twenty-three of the 100 radiographs were diagnosed as a torus/buckle fracture by all 9 surgeons. κ analysis performed on all the treatment and management questions showed that each query had poor agreement. Conclusions The interobserver reliability of diagnosing pediatric distal radius fractures showed only fair agreement. This study demonstrates that there is no standardization regarding how to treat these fractures and the length of immobilization required for proper fracture healing. Better classification systems of distal radius fractures are needed that standardize the treatment of these injuries. Level of evidence Level II.

The goal of this study was to compare open reduction versus percutaneous fixation of adolescent ankle fractures with regards to the incidence of growth disturbance. We performed a retrospective cohort analysis of adolescent patients with triplane or Tillaux fractures. There was an even distribution of triplane fractures and mean initial displacement between cohorts. Analysis of follow-up radiographs revealed no instances of growth disturbance in the percutaneous fixation group and six in the open reduction group (P=0.29). Growth disturbance does not pose a significant concern when selecting a surgical approach. Owing to the rarity of these fractures this study was underpowered.

Bone abnormalities on pediatric radiographs are not uncommon findings for both the general orthopedist as well as the specialist. Although the majority of lesions encountered are benign, the treating physician should also be aware of more concerning diagnoses. General orthopedists and pediatric orthopedists should exhibit a basic level of comfort with working up and diagnosing these benign lesions. When evaluating the pediatric patient with a bone lesion it is crucial to keep in mind important aspects of the clinical history, physical exam, and radiographic findings. Here we provide a review of important findings for the orthopedic surgeon in each of these areas. Many times diagnoses can be made with these alone. With better understanding of clinical and radiographic features of these lesions the orthopedist should be comfortable knowing which lesions he or she can reasonably treat and which should be referred to an oncologic specialist.

Purpose The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. Methods A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the products was created. Results Trampoline-related fractures rose 14% yearly from 1991 to 1999, reached a plateau from 1999 to 2003, corresponding with a 1999 AAP statement. Injury rates dropped 4.3% from 2006 to 2010 after 2005 and 2006 statements, and reached another plateau thereafter, as 2010 and 2012 statements were published. ATV-related fractures rose 14% yearly between 1997 and 2002, then dropped 15% from 2007 to 2010 following yearly AAP or AAOS statements from 2004 to 2007. From 2010 to 2014, the injury rate held constant during which time 2010, 2013, and 2014 statements were published. Lawnmower injury rates did not fall despite statements in 1998 and 2001 and a poster campaign in 2001. A 25% drop from 2007 to 2008 coincided with an AAOS statement in 2008. Fracture rates further dropped 31% from 2009 to 2011 and 21% from 2012 to 2014, amidst 2012 and 2014 statements. For ATV-related and lawnmower-related injuries, more male individuals were affected than female individuals, and for ATVs alone, injury rates increased with age. Conclusions Although AAOS/AAP statements did not universally coincide with dropping fracture rates, statements often were associated with substantial decreases in following years. This is likely because injury prevention messages are dispersed from providers to the public over time and outcomes depend on highly variable patient behaviors. Level of evidence Level V-systematic review of descriptive data.

Calcaneonavicular coalitions are an important cause of adolescent foot pain and deformity. The congenital condition is characterized by an aberrant osseous, cartilaginous, or fibrinous union of the calcaneal and navicular bones. Calcaneonavicular coalitions are the most common form of tarsal coalitions identified within epidemiologic studies. A thorough understanding of this clinically significant entity is important for restoring joint motion and preventing long-term disability.

Congenital talipes equinovarus (CTEV), more commonly known as clubfoot, is a deformity of the foot that is not well understood. The tarsal navicular is at the center of the disease process and exhibits abnormal development and delayed ossification. However, its role in the pathologic process is not clear. The aim of the present study was to better understand the role of the tarsal navicular in CTEV by correlating the presence of the navicular ossification center and relapse of clubfoot deformity after surgical treatment. The medical records and radiographs of 34 patients (41 feet) with surgically treated CTEV were reviewed for the presence of the navicular ossification center and the lateral talocalcaneal angles. Of the 41 feet, 17 (41.46%) did not have the tarsal navicular ossification center present before surgery, and 24 (58.54%) did have the ossification center present. The talocalcaneal angles were similar between those with and without the navicular ossification center present. No significant difference was found in the incidence of relapse between the nonossified navicular group (17.6%) and the ossified navicular group (16.7%; p = .63). The presence of the navicular ossification center before surgery does not appear to have prognostic value for the relapse of CTEV after surgical intervention.

Background: The absence of a reliable classification system for Legg-Calve-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenstrom classification system among a large and diverse group of pediatric orthopaedic surgeons. Methods: Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calve-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. Results: Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. Conclusions: The modified Waldenstrom classification system for staging of Legg-Calve-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

This study examined the impact of gait analysis on surgical outcomes in ambulatory children with cerebral palsy (CP) through a randomized controlled trial. 156 children with CP (94 male; age 10.2 ± 3.7 years) underwent gait analysis and were randomized to two groups: Gait Report group (N = 83), where the referring surgeon received the patient's gait analysis report, and Control group (N = 73), where the surgeon did not receive the gait report. Outcomes were assessed pre- and 1.3 ± 0.5 years post-operatively. An intent-to-treat analysis compared outcomes between the two groups. Outcome measures included the Gillette Functional Activity Questionnaire (FAQ), Gait Deviation Index (GDI), oxygen cost, gross motor function measure, Child Health Questionnaire (CHQ), Pediatric Outcomes Data Collection Instrument (PODCI), and Pediatric Evaluation and Disability Inventory. The outcomes that differed significantly between groups were change in health from the CHQ, which was rated as much better for 56% (46/82) of children in the Gait Report group compared with 38% (28/73) in the Control group (p = 0.04), and upper extremity physical function from the PODCI. Gait outcomes (FAQ and GDI) improved more when over half of the recommendations for a patient were followed or the recommended extent of surgery (none, single, or multi-level) was done (p ≤ 0.04). On average, however, only 42% of the recommendations were followed in the Gait Report group, compared with 35% in the Control group (p = 0.23). This is much less than the >85% reported in previous studies and may account for the lack of differences between groups for some of the outcome measures.

Objective The goal of this publication is to raise awareness of the impact of childhood obesity on the musculoskeletal health of children and its potential long-term implications. Methods Relevant articles dealing with musculoskeletal disorders either caused by or worsened by childhood obesity were reviewed through a Pub Med search. Efforts to recognize and combat the childhood obesity epidemic were also identified through Internet search engines. This case statement was then reviewed by the members of the pediatric specialty group of the US Bone and Joint Initiative, which represents an extensive number of organizations dealing with musculoskeletal health. Results Multiple musculoskeletal disorders are clearly caused by or worsened by childhood obesity. The review of the literature clearly demonstrates the increased frequency and severity of many childhood musculoskeletal disorders. Concerns about the long-term implications of these childhood onset disorders such as pain and degenerative changes into adulthood are clearly recognized by all the member organizations of the US Bone and Joint Initiative. Conclusions It is imperative to recognize the long-term implications of musculoskeletal disorders caused by or worsened by childhood obesity. It is also important to recognize that the ability to exercise comfortably is a key factor to developing a healthy lifestyle and maintaining a healthy body weight. Efforts to develop reasonable and acceptable programs to increase physical activity by all facets of society should be supported. Further research into the long-term implications of childhood musculoskeletal disorders related to childhood obesity is necessary.

Shoulder dislocation is relatively uncommon in the younger pediatric population. Because of the relative strength of the surrounding soft tissue structures of the shoulder compared with the proximal humeral physis, subluxation or dislocation resulting from a traumatic event or application of force is rare and instead a proximal humeral physeal injury occurs. Case presentation - We present a 5-year-old male who presented to the office with post-traumatic left shoulder pain for about 1 week. Radiographs of the left shoulder indicated inferior subluxation of the humeral head. He was ultimately diagnosed and treated for a septic shoulder. Septic arthritis of the glenohumeral joint accounts for about 3% of all septic arthritis cases. About half of the pediatric patients with a septic arthritis will present with a concomitant osteomyelitis about the joint involved. Widening of the glenohumeral joint and subluxation clinically as well as radiographically have been described in cases of large joint effusions because of an increase in intra-articular fluid in adults. This inferior subluxation is often noted without a frank dislocation. The case described in this report is unique in that this is the first to describe a pediatric septic shoulder presenting as a shoulder subluxation. Given the rarity of pediatric shoulder dislocations and subluxations, the pediatric orthopaedist and pediatrician should maintain a suspicion for a septic joint. Level of evidence Level V.

Previous studies examining the influence of gait analysis on surgical decision-making have been limited by the lack of a control group. The aim of this study was to use data from a randomized controlled trial to determine the effects of gait analysis on surgical decision-making in children with cerebral palsy (CP). 178 ambulatory children with CP (110 male; age 10.3±3.8 years) being considered for lower extremity orthopaedic surgery underwent gait analysis and were randomized into one of two groups: gait report group (N=90), where the orthopaedic surgeon received the gait analysis report, and control group (N=88), where the surgeon did not receive the gait report. Data regarding specific surgeries were recorded by the treating surgeon before gait analysis, by the gait laboratory surgeon after gait analysis, and after surgery. Agreement between the treatment done and the gait analysis recommendations was compared between groups using the 2-sided Fisher's Exact test. When a procedure was planned initially and also recommended by gait analysis, it was performed more often in the gait report group (91% vs. 70%, p0.001). When the gait laboratory recommended against a planned procedure, the plan was changed more frequently in the gait report group (48% vs. 27%, p=0.009). When the gait laboratory recommended adding a procedure, it was added more frequently in the gait report group (12% vs. 7%, p=0.037). These results provide a stronger level of evidence demonstrating that gait analysis changes treatment decision-making and also reinforces decision-making when it agrees with the surgeon's original plan.

Aim To determine whether there is a difference between perspectives of functioning and health-related quality of life (HRQL) of parents and ambulatory adolescents with spastic cerebral palsy (CP). Method A total of 139 parent patient pairs (73 females, 66 males; median age 14y 6mo, age range 11–18y, Gross Motor Function Classification System [GMFCS] levels I–III, with hemiplegia [n=23], diplegia [n=103], triplegia [n=9], and quadriplegia [n=4]) were recruited from outpatient CP clinics at three pediatric orthopaedic hospitals, between 2000 and 2006, from whom Pediatric Outcomes Data Collection Instrument (PODCI) responses were collected. Results Cross-sectional data, calculated with intraclass correlation coefficients [ICC], showed parents and adolescents agreed more on functioning (ICC=0.488–0.748) than HRQL (ICC=0.242–0.568; PODCI). Parents and adolescents both recognized significant comorbidities (ICC=0.502–0.713), but adolescents saw themselves as less limited (ICC=0.330) than parents. The greatest differences between parents and adolescents were in HRQL scales for male adolescents, with only a small part explained by GMFCS level difference between sexes (effect size 0.002–0.143). Age, parent well-being, and parent sex had little effect and comorbidities had no effect. GMFCS level was the most common predictor. Interpretation Most scales on health conditions, function, and HRQL agreed between parents and adolescents aged11 to 18 years. Parent proxy is reasonable when necessary, but assessing both parents and adolescents gives additional insight. Adolescents do not consider themselves as limited by health conditions as parents do; parents have greater satisfaction with current level of symptoms than adolescents, and findings vary on expectations for treatment.

Recent studies have questioned the efficacy of releasing hip flexion contractures and the resulting ankle position after tendoachilles lengthening in ambulating children with cerebral palsy (CP).Twenty-three ambulatory children with CP underwent 96 soft tissue-lengthening procedures without bony surgery. Preoperative and postoperative clinical and computerized gait data were reviewed.Static contractures improved reliably, with improvements in all areas measured, including hip flexion contracture (14 degree improvement), hip abduction (19 degree improvement), popliteal angle (26 degree improvement), and ankle dorsiflexion (11 degree improvement). The changes in computerized gait data were less uniform. The knees showed significant benefits, as evidenced by improved maximal knee extension in stance phase (37.3 degree preop and 19.9 degree postop) and at initial contact (51.6 degree preop and 34.8 degree postop). At the hip, a statistically significant improvement was only seen in maximum hip extension in stance phase (minimum hip flexion), and the magnitude of this change was only 4.6 degree (15.3 to 10.7 degree). There were no significant changes at the pelvis. At the ankle, the tendency was toward calcaneal gait after Achilles tendon lengthening, with excessive dorsiflexion seen both in stance (17.3 degree) and at toe off (-6.9 degree). Tempero-spatial parameters showed improved stride length, but no significant changes in gait velocity or cadence.The persistence of crouch postoperatively, though improved, likely limited the potential changes in hip kinematics. As this study excluded patients undergoing osseous surgery, it is possible that lever arm dysfunction may have contributed to the ongoing crouch. The results of this study suggest that static contractures and knee kinematics improve reliably after soft tissue surgery in children with CP, but that caution must be exercised when considering heel cord lengthening in these children.Therapeutic level II. See Instructions to Authors for a complete description of levels of evidence.

The Child Health Questionnaire (CHQ), Pediatric Outcomes Data Collection Instrument (PODCI), and Pediatric Evaluation and Disability Inventory (PEDI) are the 3 instruments commonly used to measure function and quality of life in pediatric orthopaedics. This study compared answers to specific questions on the CHQ, PODCI, and PEDI given by the parents of 66 children with cerebral palsy, who completed all 3 questionnaires. Both Spanish- and English-speaking subjects were included. No overlapping questions were found between the CHQ and PEDI. Of the 8 questions that overlapped between the CHQ and PODCI, 2 questions (general health and change in health) had weighted kappa greater than 0.70, with responses within +/-1 point for more than 95% of respondents. These 2 questions had almost exactly the same wording on both questionnaires. The other 6 questions had fair to poor agreement between questionnaires (kappa, 0.10-0.55). All 5 questions that were addressed by both the PODCI and PEDI also had poor agreement (kappa < 0.40). There was little correspondence between the preconceived match quality and the actual matching results (r=0.41; P=0.16). These results suggest that differences in wording have a significant and unpredictable effect on parents' responses; this should be considered when selecting from among different instruments. Of the instruments used in this study, the CHQ is the easiest to administer and is a good general quality of life measure; however, the PODCI or PEDI may be preferred if information about more specific functional activities is desired.

All orthopedic surgeons face moral dilemmas on a regular basis; however, little has been written about the moral dilemmas that are encountered when providing orthopedic care to pediatric patients and their families. This article aims to provide surgeons with a better understanding of how bioethics and professionalism apply to the care of their pediatric patients. First, several foundational concepts of both bioethics and professionalism are summarized, and definitions are offered for 16 important terms within the disciplines. Next, some of the unique aspects of pediatric orthopedics as a subspecialty are reviewed before engaging in a discussion of 5 common moral dilemmas within the field. Those dilemmas include the following: (1) obtaining informed consent and assent for either surgery or research from pediatric patients and their families; (2) performing cosmetic surgery on pediatric patients; (3) caring for pediatric patients with cognitive or physical impairments; (4) caring for injured pediatric athletes; and (5) meeting the demand for pediatric orthopedic care in the United States. Pertinent considerations are reviewed for each of these 5 moral dilemmas, thereby better preparing surgeons for principled moral decision making in their own practices. Each of these dilemmas is inherently complex with few straightforward answers; however, orthopedic surgeons have an obligation to take the lead and better define these kinds of difficult issues within their field. The lives of pediatric patients and their families will be immeasurably improved as a result. [ Orthopedics. 2015; 38(12):e1133–e1138.]

Background The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP. Methods We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology. Results Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings. Conclusions Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research. Level of evidence Level 4-literature review.

The AAOS Evidence-Based Guideline on Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age includes both diagnosis and nonoperative management. This clinical practice guideline has been endorsed by the American Academy of Pediatrics (AAP), the Pediatric Orthopaedic Society of North America (POSNA), the Society for Pediatric Radiology (SPR), and the Society of Diagnostic Medical Sonography (SDMS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was …

BACKGROUND There is a dearth of literature examining the causes of cam-type femoroacetabular impingement (FAI) and when such morphology appears. The purpose of the current study was to analyze how the ossific portion of the proximal femur develops over time with respect to standard cam-type FAI parameters. METHODS A collection of 193 femurs from cadavers aged 4 to 21 years were evaluated. The age, sex, ethnicity, and status of the proximal femoral physes (open or closed) of each were recorded. Each specimen was digitally photographed in standardized anteroposterior and modified axial positions. From these photographs, the anterior offset, anterior offset ratio (AOR), and α-angle were determined. A cam lesion was defined as an α-angle >55 degrees on the lateral view. RESULTS The mean age of the specimens was 17.5±4.2 years. The majority were male (69%) and African American (79%) with closed physes (78%). There were significant differences among discrete age groups with respect to α-angle (P=0.01), anterior offset (P

Background Children who present with idiopathic slipped capital femoral epiphysis (SCFE) have an increased risk of developing bilateral disease. Predicting which patients will develop problems with bilateral hips is important for determining treatment algorithms. This is a retrospective observational study that evaluates the relationship and risk between body mass index (BMI)-for-age and unilateral and bilateral SCFE in patients followed until physeal closure. Methods This is a retrospective study of all patients with SCFE presenting to one institution from 1998–2005. Using the Center for Disease Control (CDC) references, BMI-for-age was calculated for each patient. The patients were followed up until complete closure of the bilateral proximal femoral physes, which was considered completion of the study. Statistical analysis for significant differences between groups was performed using the Kruskal–Wallis test for equality of populations. A logistic regression, controlling for age and gender, was used to identify BMI-for-age as a risk factor and to determine the significance of the odds ratios (ORs) for the relevant categorical variables—obese, overweight and healthy weight. Results Eighty patients (56 male, 24 female) presented to a single institution between 1998 and 2005 with a diagnosis of SCFE. The mean age of patients was 12.2 years at initial presentation (range 8.5–16). Forty-eight patients (32 male, 16 female) presented with unilateral SCFE, with 22 of the 48 patients having a BMI for-age percentile ≥95 %. Thirty-two patients (24 male, 8 female) presented with bilateral SCFE, with 29 of the 32 patients having a BMI-for-age percentile ≥95 %. Patients with a BMI-for-age ≥95 % had a significantly increased risk of presentation with bilateral slips (OR 4.83; relative risk [RR] 3.01; p < 0.05]. All but one patient in this study with bilateral SCFE or unilateral SCFE with subsequent contralateral involvement had a BMI-for-age ≥85 % (44 out of 45 patients). Additionally, the overall risk of developing bilateral SCFE until physeal closure with a BMI-for-age ≥95 % was significantly increased (OR 3.84; RR 2.02; p < 0.05; number needed to treat [NNT] 3.01). Conclusions Previous work has established a relationship between BMI and SCFE. The CDC BMI-for-age growth charts more accurately measure obesity in the pediatric population compared to BMI and are therefore a more appropriate reference tool. This study demonstrates an association between obesity measured by BMI-for-age percentiles and SCFE. This study also demonstrates an association between BMI-for-age and risk for bilateral SCFE at presentation as well as overall incidence of developing bilateral SCFE in the obese pediatric population. By defining the at-risk population through BMI-for-age, physicians can screen the pediatric patient population and provide early strategies for therapeutic weight loss which may reduce the incidence of SCFE.

STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine predictors of and 30-day complications associated with blood transfusion volume after posterior spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program pediatric database from 2012 to 2013. Patients were stratified on the basis of blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS A total of 1691 patients were included. Male sex (P = 0.010), esophageal or gastrointestinal disease (P = 0.016), cardiac risk factors (P = 0.037), preoperative inotrope requirement (P = 0.031), total operative time of 300 minutes or more (P < 0.001), and posterior arthrodesis of 13 or more vertebral segments (P < 0.001) were independent risk factors for requiring blood transfusion. Total transfusion volume of 20 mL/kg or more was the minimum volume independently associated with increased rates of total complications (P = 0.018), with a complication rate of 5.9%. CONCLUSION We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications after posterior arthrodesis for AIS. Although transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates. LEVEL OF EVIDENCE 4.

Background: Although a plethora of literature exists on the impact of body mass index (BMI) in orthopaedic surgery, few have examined its implications in the pediatric cerebral palsy (CP) population. The aim of this study is to evaluate the effect of BMI class on 30-day complications after orthopaedic surgery on children with CP. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric participant use files from 2012 to 2013 was conducted. Patients with a diagnosis of CP undergoing any orthopaedic procedure were included and subclassified according to BMI classes: underweight, normal weight, overweight, and obese. Multivariate logistic regressions were performed to evaluate the independent effect of BMI class on total, surgical site, and medical complications as well as unplanned reoperations. Results: A total of 1746 patients were included in our study. These included 345 (19.8%) underweight, 952 (54.5%) normal weight, 209 (12.8%) overweight, and 240 (13.7%) obese children and adolescents. In hip and lower extremity osteotomies, underweight class was an independent risk factor for total complications (P = 0.037) and medical complications (P = 0.031). Similarly, underweight class was a risk factor for total complications (P = 0.022) and medical complications (P = 0.019) in spine procedures. Weight class was not independently associated with complications in tendon procedures. Overweight and obesity classes were not associated with any independent increased risk for complications. Conclusions: With respect to the pediatric CP population, underweight status was deemed an independent predictor of increased complications in osteotomies and spine surgery with no independent increased risk in the overweight or obese cohorts. This information can greatly aid providers with risk stratification, preoperative counseling, and postoperative monitoring as it relates to orthopaedic surgery. Level of Evidence: Prognostic level III.

Pediatric scoliosis often requires operative treatment, yet few studies have examined readmission rates in this patient population. The purpose of this study is to examine the incidence, reasons, and independent risk factors for 30-day unplanned readmissions following scoliosis surgery.A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric database from 2012 to 2013 was performed. Patients undergoing spinal arthrodesis for progressive infantile scoliosis, idiopathic scoliosis, or scoliosis due to other medical conditions were identified and divided between 2 groups: patients with unplanned 30-day readmissions (Readmitted) and patients with no unplanned readmissions (Non-Readmitted). Multivariate logistic regression models were created to determine independent risk factors for readmissions.A total of 3482 children were identified, of which 120 (3.4%) had an unplanned readmission. A majority of patients had a readmission due to a surgical site complication regardless of scoliosis etiology. Risk factors for readmission included obesity (P0.001) and posterior fusion of 13 or more vertebrae (P=0.029) for idiopathic scoliosis, impaired cognition (P=0.009) for progressive infantile scoliosis, and pelvic fixation (P=0.025) and American Society of Anesthesiologist ≥3 (P=0.048) for scoliosis due to other conditions.We present 30-day readmissions risk factors based on independent patient and procedural risk factors. This may be useful in the clinical management of patients following scoliosis surgery, specifically for the role of preoperative and predischarge risk stratification.

As the increasing prevalence of overweight and obese children is approaching epidemic proportions in North America, this study was designed to investigate whether Body Mass Index (BMI) and age- and gender-specific percentile Body Mass Index (BMI %) are associated with the likelihood of being listed for surgery for Blount disease after initial presentation to a tertiary referral centre. In a restrospective consecutive sample of 102 children with an average age of 5.9 +/- 4.3 years, it was determined that there was a significant association between BMI and BMI% and being listed for surgery, after adjusting for the effects of the child's age and gender, with mean odds ratios of 1.30 (95% confidence interval 1.02-1.60) and 1.05 (95% confidence interval 1.01-1.09) respectively. When the sample was subgrouped into infantile (less than 3 years of age) and late-onset (greater than 3 years of age), BMI and BMI% were still significantly associated with the children being listed for surgery in the late-onset group with mean odds ratios 2.75 (95% confidence interval 1.03-7.33) and 1.09 (95% confidence interval 1.01-1.18) respectively. However, of the two measures only the BMI was significant in the infantile group with an odds ratio of 1.27 (95% confidence interval 1.01-1.60). Should these associations be real then measures aimed at decreasing weight in children may have some effect on the number of children undergoing surgery for the treatment of Blount disease.

This is a series of 7 children (14 hips) with a mean age of 7.3 years (range, 3.3-10.5 years) and an underlying diagnosis of developmental dysplasia of the hips and no previous open-hip surgery who underwent plain radiographic and magnetic resonance imaging (MRI) measures of bony acetabular index. There was a significant correlation between the measurement of acetabular index using plain radiography and MRI, with a Spearman correlation coefficient of 0.88 (95% confidence interval, 0.61-0.96; P

The aim of management of the child with a severe, rigid equinovarus foot is to provide a foot that is plantigrade and painless and can be placed within standard footwear. The authors identified a retrospective cohort of 17 children with a mean age at surgery of 5.6 years (range 2.3-9.6 years) who underwent 31 talectomy procedures for the management of their rigid, equinovarus foot deformities (14 isolated talectomies, 17 combined talectomy and calcaneocuboid fusions). The underlying diagnosis was predominantly arthrogryposis. The average follow-up was 9.7 years (range 2.3-9.5 years) and 3.8 years (range 2.8-9.6 years) respectively. The addition of calcaneocuboid fusion prevented the development of postoperative equinus, varus, adductus, and supination deformities as determined by clinical examination at medium-term follow-up (P = 0.01, P < 0.001, P < 0.001, P < 0.001, P < 0.01, respectively). This was associated with a decreased incidence of recurrent foot pain with weightbearing (P < 0.001) and a reduced need for revision surgery for pain or deformity (P < 0.001). This study determined that the addition of a concomitant calcaneocuboid fusion in the setting of talectomy may improve the medium-term surgical outcome.

A retrospective analysis of 90 patients (37 boys, 53 girls) with myelomeningocele was performed to determine the relationship between gender, presence of hydrocephalus, and level of myelomeningocele with skeletal maturity, as measured by bone age. Bone age was assessed using the Oxford method of skeletal maturity. A ventriculoperitoneal shunt was present in 56 of the 90 patients. The mean bone age was found to be significantly less in patients with a ventriculoperitoneal shunt. There was no difference in bone age when comparing gender or level of myelomeningocele. Identification of factors affecting skeletal maturity in patients with myelomeningocele is important in surgical planning for therapeutic operations such as osteotomies, timing of epiphysiodesis, and spinal fusion for scoliosis.

Patients with myelodysplasia have increased wound dehiscence and ulcer formation compared with the normal population. While neurologic deficits and resultant muscle imbalance are the presumed etiologies for these complications, no study has investigated the role of peripheral circulation in myelodysplasia. Eighty-two patients (ages 2-20) were prospectively recruited for this study, consisting of 41 patients with myelodysplasia and 41 age-matched controls. Peripheral circulation was quantified using systolic blood pressures in arms and legs (ankle-brachial index [ABI]) and transcutaneous pO 2 measurements (TcO 2 ) in a standardized location in the forefoot. Both groups had similar mean age. Patients with myelodysplasia had a lower ABI but similar TcO 2 compared with the control group. Among the patients with myelodysplasia, the ABI and TcO 2 did not vary according to the level of neurologic deficit or the patient's age. However, those with prior surgical procedures had significantly higher ABI and TcO 2 compared with those without prior surgery (P < 0.05). This study suggests that patients with myelodysplasia may have decreased peripheral circulation compared with normal controls. Vascular insufficiency may therefore contribute to increased wound healing complications and ulcer formation in these patients.

Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients ( 11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.

Two cases of clavicle fractures associated with atlantoaxial rotatory displacement as well as 11 additional cases from the literature are presented. Most cases occur in girls 6 to 10 years old. The head is most often laterally bent toward and rotated away from the fractured clavicle. There is often a delay in making the diagnosis, which is best demonstrated by dynamic CT. Treatment of the clavicle fracture is straightforward, but failure to recognize and treat the C1-2 rotatory displacement promptly can lead to fixed C1-2 deformity. Displacement recognized within the first 3 weeks of injury can be successfully treated nonoperatively. A delay of 6 weeks or greater in the diagnosis leads to fixed deformity at C1-2 that can be addressed with a limited cervical fusion.

In a retrospective review of 74 tibial osteotomies performed for Blount disease, the patients were divided into three groups based on age and treatment. Group A (26 osteotomies), 4 years old or younger, and group B (34 osteotomies), older than 4 years, were treated the same with osteotomy and crossed pins. Group C (14 osteotomies), older than 4 years, was treated with osteotomy and external fixator. At 6 years of follow-up, the recurrence of varus deformity was 46%, 94%, and 72% in groups A, B, and C, respectively. There was no correlation between recurrence of varus deformity and preoperative deformity angle or degree of surgical correction. Fixation with crossed pins or external fixator was not a factor. Surgery at 4 years old or younger and correction of the postoperative deformity angle in valgus may obviate recurrence of varus deformity in Blount disease at long-term follow-up.