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Background: Cast room procedures can be a source of considerable distress for pediatric patients. High levels of anxiety can make it difficult to perform procedures effectively and may negatively affect the doctor-patient relationship. We sought to evaluate available interventions to reduce anxiety in pediatric patients undergoing orthopaedic cast room procedures., Methods: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022333001, May 28, 2022). PubMed, EBSCO host, MEDLINE, Cochrane, and Google Scholar electronic databases were used to identify all studies evaluating interventions to reduce pediatric anxiety during orthopaedic cast room procedures between January 1, 1975, and June 1, 2022. The quality of included studies was assessed using the Jadad scale., Results: Our initial search yielded 1,490 publications, which were then screened for appropriate studies that aligned with the purpose of our review. Fourteen studies comprising 8 prospective cohort and 6 randomized controlled trials were included. The total sample size of included studies consisted of 1,158 patients with participant age ranging from 1 to 21 years. The interventions investigated included noise reduction headphones, musical therapy, inclusion of a certified child life specialist, casting shears, virtual reality, Bedside Entertainment and Relaxation Theater (BERT), children's and instructional videos, and video games. Most of the included interventions were effective at reducing anxiety during cast room procedures. However, there was variation in anxiety reduction across cast room procedure and treatment modality., Conclusion: The use of physical or technology-based distraction tools can play an important interventional role in improving patient satisfaction during cast room procedures. The majority were inexpensive, readily applicable to the clinical setting, and of negligible risk to the patient., Level of Evidence: Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A902)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The optimal treatment of displaced middle-third clavicular fractures in pediatric and adolescent patients remains controversial. Furthermore, risk factors for the failure of nonoperative treatment have not been clearly defined. Therefore, we designed a systematic review and critical analysis to assess appropriate Grades of Recommendation for evidence-based treatment of middle-third clavicular fractures in the pediatric and adolescent populations., Methods: We performed a systematic review following a search of the PubMed, Embase, and Cochrane databases that was conducted in May 2017. The search terms were clavicle, clavic*, and fracture. Our specific PubMed search was ("clavicle"[MeSH] OR clavic*) AND ("fracture"[MeSH] OR fracture*). The results were filtered for English language and subjects ≤18 years of age. There was no chronological limit on the results. The results were then assessed for relevance via a stepwise approach by first screening titles, then abstracts, and, finally, full text. The levels of evidence were determined for studies that met the inclusion criteria. The findings were summarized, and Grades of Recommendation were assigned by consensus., Results: Our search returned 3,615 studies. Of these, 215 were potentially relevant. Studies that did not meet our inclusion criteria were removed by consensus. One hundred and nineteen full-text articles were then assessed. Of these, 19 met the inclusion criteria. Overall, patients with both operative and nonoperative treatment of displaced middle-third clavicular fractures have good functional outcomes, with Grade-B supporting evidence. There is Grade-B evidence that operative treatment results in a high complication rate. Both plating and nailing have a high likelihood of requiring implant removal, with Grade-B evidence. There is conflicting evidence regarding the effect of both nonoperative and operative treatment on patient cosmesis following displaced fractures. There is Grade-B evidence that nonunions of pediatric clavicular fractures are exceptionally rare, regardless of treatment strategy. Nonoperatively treated displaced fractures have conflicting evidence regarding any adverse effect displacement may have on functional status., Conclusions: Existing literature does not clearly delineate appropriate indications for nonoperative care or relative indications for operative intervention. Further studies are needed to guide treatment and promote better informed consent., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.