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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.

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.

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.

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.

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.

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.

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.

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.

Purpose Chondroblastoma is a benign, but potentially locally aggressive, bone tumor with predilection for the epiphysis of long bones in growing children. Historically, there is a reported 2% risk of lung metastasis, however these cases are mostly in the form of isolated single reports and the vast majority in adults. The purpose of this study was to identify the "true" risk of lung metastases at presentation in skeletally immature patients with a benign chondroblastoma, and therefore revisit the need for routine chest staging. Methods This was a multi-institution, international retrospective study of children and adolescents diagnosed and treated for a benign chondroblastoma. We focused on the screening and diagnosis of lung metastasis, type of staging utilized and the incidence of local recurrence. Detailed review of the available literature was also performed for comparison. Results The final studied cohort included 130 children with an average age of 14.5 years (range: 6 to 18 y). There were 94 boys and 36 girls. Lesions more often involved the proximal humerus (32/130), proximal tibia (30/130), and proximal femur (28/130). At an average follow-up of 50 months, there were 15 local recurrences (11% rate) and no cases of lung metastasis. All patients underwent chest imaging at presentation. The overall reported lung metastases rate in the pulled literature review (larger series only) was 0.4% (7/1625), all patients were skeletally mature. Conclusions This is the largest cohort of pediatric-exclusive chondroblastoma in the literature. Despite minor differences in management between the centers included, the recurrence rate was similar and there was no evidence of lung metastasis (0 in 130). The incidence of distant involvement in a true benign chondroblastoma in children is much lower than the 2% previously reported in the literature, and the need for routine chest staging should be revisited. Level of evidence Level III.

Optimal treatment of pediatric both bone forearm fractures is determined by patient age, fracture pattern, and location. As compared to their adult counterparts, pediatric patients can generally tolerate more displacement and angulation because of their increased remodeling potential. The mainstay of treatment for these injuries continues to be closed reduction and casting. However, operative fixation has increased significantly over the past decade. Currently, both flexible intramedullary nailing and plate fixation are acceptable options in this population. Flexible intramedullary nailing has the advantage of decreased surgical dissection and preservation of local biology, as well as decreased operative times; however, this treatment option may necessitate a return to the operating room for hardware removal. Open reduction and internal fixation with plates and screws may more accurately restore bony anatomy, with the potential to retain the implants. However, the optimal method of fixation has not been established and outcomes with both techniques appear to produce satisfactory results in a majority of patients. The purpose of this review is to provide an overview of the treatment options for these common pediatric and adolescent injuries.

Sumario 1. Apresentacao e Introducao……………………………………………………330 2. Avalicao Pre-Participacao………………………………………………………330 […] Atualizacao da Diretriz em Cardiologia do Esporte e do Exercicio da Sociedade Brasileira de Cardiologia e da Sociedade Brasileira de Medicina do Exercicio e Esporte – 2019

OBJECTIVE Adults with congenital heart disease share some features with those with chronic heart failure. Although microvascular endothelial dysfunction has been described in chronic heart failure, evaluation of the microcirculation in adults with congenital heart disease is lacking. The present study aimed to investigate systemic microvascular reactivity in adults with congenital heart disease. INTERVENTIONS The patients initially underwent cardiopulmonary exercise testing. Then, the cutaneous microvascular reactivity was evaluated in these patients using a laser speckle contrast imaging system coupled with skin iontophoresis of endothelial-dependent (acetylcholine) or -independent (sodium nitroprusside) vasodilators and postocclusive reactive hyperemia (PORH) and compared with healthy controls matched for age and sex. RESULTS Thirty-one patients and 29 healthy controls were evaluated. The basal microvascular flow (P

Introduction Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition. Methods A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment. Results A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union. Conclusion Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases. Level of evidence Level IV-retrospective case review.

PURPOSE This study compared the effects of low and high weekly exercise frequencies on microvascular endothelium function and oxidative stress among patients with coronary artery disease. METHODS Thirty-four male patients completed a 6-month cardiac rehabilitation programme, from which 23 performed exercise with a high frequency (HF) and 11 with a low frequency (LF). Systemic microvascular blood flow, maximal aerobic capacity, blood lipids, oxidative stress and anthropometric data were assessed prior to and after the cardiac rehabilitation programme. Microvascular blood flow was assessed in the skin of the forearm using laser speckle contrast imaging coupled with iontophoresis of acetylcholine. RESULTS Maximal aerobic capacity, biochemical analysis and anthropometric data were similar between groups prior to and after the cardiac rehabilitation programme (P>0·05). However, after 6 months of cardiac rehabilitation performed with HF, there was an increase in the peak response to acetylcholine compared with LF (83·5 ± 58·5 versus 21·8 ± 22·4%; P

Xanthogranulomatous osteomyelitis (XO) is an exceedingly rare disease characterized by infiltration of histiocytes and foamy macrophages. Both on gross examination and on radiographs, XO can mimic malignancy. We describe the case of a 5-year-old female with Alagille syndrome who presented with a pathologic fracture of the right humerus. Initial radiographs revealed multiple osteolytic lesions in the distal humerus while MRI showed a large soft tissue mass. Biopsy confirmed the diagnosis of XO, which has hitherto not been described in a patient with Alagille syndrome. The patient was admitted for IV antibiotics and taken to the operating room for an incision and debridement. Tissue cultures were obtained and grew Salmonella. Antibiotic therapy was tapered, and the patient responded to treatment. She was doing well at her 6-month follow-up visit. In the discussion section, we explore how osteopenia and immune dysregulation caused by Alagille syndrome can affect the development of XO. We summarize all previously reported cases of XO and conclude that XO presents as an osteolytic lesion that expands rapidly over the course of a few weeks. We highlight that XO can mimic sarcoma because of its mass effect but can be distinguished radiographically by the presence of surrounding sclerosis. Given the rapid onset of XO, we classify it as an acute osteomyelitis. We discuss how leukemia and Ewing sarcoma can present similarly to acute osteomyelitis. We then emphasize key features that can be used to distinguish these malignancies from acute osteomyelitis.

BACKGROUND Forearm deformity occurs in one third of patients with multiple hereditary exostoses (MHE). Conservative and surgical treatment are aimed at preventing radial head subluxation and/or dislocation. Dislocation has been associated with isolated distal ulnar lesions, radial bowing, and ulnar shortening. Risk factors for radial head subluxation have not been clearly elucidated. This study aimed to identify risk factors for all radial head instability in MHE, to optimize early detection and prevent frank dislocation. METHODS This multicenter retrospective case-control investigation included MHE patients with forearm lesions seen between 2000 and 2017 at 2 tertiary care children's hospitals. Demographic, clinical factors, radiographic measures, and surgical history were quantified. Comparisons were made between forearms that developed radial head instability versus those that remained stable and between those that progressed to radial head subluxation versus those that progressed to dislocation. RESULTS This study included 171 forearms in 113 patients with MHE, who presented at a mean age of 8.0 years with a median follow-up time of 6.0 years. Nine forearms progressed to radial head subluxation (mean age: 10.2 y), and 24 forearms had radial head dislocation (mean age: 9.9 y). Five subluxations and 3 dislocations occurred despite preventative surgery. Initial radial bowing (7.2% vs. 8.5%, P=0.04), ulnar variance (-5.8% vs. 11.0%, P

Avascular necrosis (AVN) of the distal humerus is a known complication of lateral condyle fractures yet the specific rate of occurrence is unknown. The purposes of this study are to analyze the incidence, outcomes, and risk factors for AVN following lateral condyle fractures. A retrospective chart review of children diagnosed with a lateral condyle fracture between 2001 and 2014 at level-1 tertiary pediatric center was completed. Demographic data, Weiss classification, time from injury to surgery, operative vs. nonoperative management, open vs. closed reduction, and type of fixation were studied. For patients with radiographs consistent with AVN at any point in their care, elbow range of motion (ROM), pain, and deformity were measured at last follow up. Of the 500 patients evaluated, the incidence of AVN was 1.4%. All cases of AVN were following open reduction and percutaneous fixation (P = 0.01) as initial treatment. Type III fractures were significantly associated with AVN (P = 0.041). After average follow up of 59 weeks (range: 24-150 weeks), all patients regain full ROM except one patient who lacked of 15° of extension and 10° of flexion. Five patients were asymptomatic while two patients had mild pain. There was no radiographic evidence of valgus or varus deformity at final follow up. AVN following lateral condyle fractures is rare with a rate of only 1.4%. Type III fractures and open reduction were significantly associated with AVN. Provided no residual deformity and reconstitution of avascular bone, good outcomes can be expected.

Background Systemic inflammatory response syndrome (SIRS) is a well-recognized phenomenon in adult trauma populations. The "initial hit" of the traumatic event is often coupled with a systemic immune response characterized by changes in vital signs and laboratory indicators. A "second hit" from surgery during this time frame often results in acute lung injury, along with deterioration of the patient's clinical condition. We hypothesized that children and adolescents would experience SIRS physiology, but would not experience adult respiratory distress syndrome (ARDS) or "second hit" related death to the extent seen in the adult populations. Methods We queried the trauma database of our level 1 pediatric trauma center from January 2005 to December 2015 for patients with injury severity scores of >16. We used the electronic medical record to track SIRS criteria in patients days 1 to 4 posttrauma. Trends were examined in patients with an orthopaedic injury (OI) and with no orthopaedic injury. Patients were further subcategorized and analyzed by age group based on the convention for definition of pediatric SIRS. Patients in the orthopaedic cohort were further examined for pulmonary complications and death. Logistic regression was used to identify risk factors for SIRS physiology in the first 4 days of hospitalization. Results 81.4% (OI) and 69.1% no orthopaedic injury reached the threshold for SIRS within their first 4 days of hospitalization. Nine patients died in the hospital. Only 3 OI patients developed the criteria for ARDS, and only 3 patients with orthopaedic injuries died, 2 died within 24 hours of presentation and 1 within 48 hours, all had severe brain trauma. Increasing age groups showed increasing proportion of patients with SIRS. Increasing injury severity score and increasing age were independent predictors of SIRS during days 1 to 4. Discussion SIRS seems to be as common in children as the reported rates for adults, and the proportion of SIRS in children increases with increasing age and injury severity. The high mortality rate and rate of ARDS observed in adults was not observed in our cohort. The presence or absence of major orthopaedic injuries was not a significant predictor. The SIRS response in polytraumatized children is poorly understood. The clinical phenomenon of acute lung injury/ARDS is observed less often in children, but the exact mechanism by which this occurs is unknown. Level of evidence Level III-case control.

Background Vitamin A-derived retinoids have been reported to cause skeletal abnormalities ranging from hypercalcemia to premature epiphyseal closure. Isotretinoin is a retinoid used as standard therapy for high-risk neuroblastoma and has been reported to cause premature epiphyseal growth plate arrest. Procedure We identified patients from the Children's Hospital Los Angeles (CHLA) database with high-risk neuroblastoma diagnosed from 1991 to 2018 who experienced premature epiphyseal growth plate arrest and compared their characteristics to other patients with high-risk neuroblastoma. We then performed a literature review of this complication. Data collection included diagnosis age of neuroblastoma, presentation age, agent of exposure, dose, exposure range, and skeletal deformity. Results Among 216 patients, high-risk neuroblastoma was diagnosed before age of five years (n = 165), between ages of 5 and 10 years (n = 41), and after 10 years of age (n = 13). Three out of 216 patients developed premature epiphyseal growth arrest after isotretinoin exposure (overall incidence = 1.38%). The incidence of bony abnormalities was significantly higher in patients diagnosed in 5- to 10-year age group than in other two groups (P = 0.014). Literature review identified eight additional patients with neuroblastoma who presented with retinoid associated skeletal abnormalities. The median range of isotretinoin exposure for these 11 patients was between 6.5 and 7.625 years (range, 2-14) with no cases of isotretinoin therapy completion before age 5 years. Conclusion Bone toxicity associated with isotretinoin exposure is a concern. Growth plate arrest is a serious adverse effect that is attributable to isotretinoin therapy. Our findings suggest the prepubescent growth plate may be most at risk, and we recommend special attention to this population.

Anterior–posterior (A/P) radiography of the pelvis is essential to the diagnosis and treatment of developmental dysplasia of the hip (DDH). Multiple well-defined parameters of adult hip morphology with good reliability are readily available. The purpose of this study was to determine normative values and observed reliability for 10 common adult hip parameters in the developing pelvis of male and female patients aged 6 months–16 years. One hundred and fifty-eight standardized A/P pelvic radiographs were randomly selected from an existing trauma patient database and stratified into five age groups. Mean values or presence of categorical values and the observed reliability of 10 adult hip parameters (acetabular index/angle, pelvic width index, lateral center edge angle, Tonnis angle, acetabular to femoral head distance, femoral head diameter, coxa profunda/protrusio, ischial spine sign, crossover sign and posterior wall sign) were determined. Minimal differences in all parameters were observed between male and female patients. The observed inter-rater reliability of continuous parameters was 0.77–0.99. The observed intra-rater reliability was 0.7–0.99 with a combined intra-rater reliability of 0.88–0.99. The observed inter-rater reliability of categorical variables was 0.64–1.0. The intra-rater reliability of categorical variables was 0.83–1.0. Normative values for 10 common adult hip parameters were determined for male and female patients in the developing pelvis. Reliable knowledge of these values and their relationship to the age of the patient and/or stage of pelvic development associated may provide additional information to aid the treatment of DDH.

Background The management of septic arthritis of the hip in children can be complicated by the presence of additional coexisting periarticular infections (PAIs). Criteria predicting the presence of PAI have recently been proposed by Rosenfeld and colleagues with the goal of using magnetic resonance imaging (MRI) efficiently in the workup of septic arthritis. The purpose of this study was to determine the applicability of recently published predictive criteria for PAI (developed in the Southwestern United States using a variety of joints) to septic arthritis of the hip treated at a large Northeastern tertiary care center. Methods We studied patients treated for septic arthritis of the hip with irrigation and debridement in a large Northeastern tertiary care center over a 10-year period. Laboratory and clinical variables related to presentation, treatment, and outcome were collected. Subjects with and without a perioperative MRI were compared with published criteria by Rosenfeld and colleagues. Results Fifty-one subjects (53 hips) were identified with a mean age of 7.0 years (range, 1.2 to 19.3 y) and mean follow-up was 16 months (range, 2 to 85 mo). MRIs were obtained in 20 subjects (43%). Coexisting osteomyelitis was revealed in 7/20 of these studies (35% of MRIs); 4 of which showed coexisting intramuscular abscesses. Within our MRI cohort, the Rosenfeld criteria were found to have a sensitivity of 86%, a specificity of 54%, and a false-positive rate of 50% for the hip (compared with originally reported sensitivity of 90%, specificity of 67%, and false-positive rate of 33%). Overall, advanced imaging changed management in 5/51 patients (9%) by influencing the need for further treatment, whereas the remainder underwent isolated treatment of the septic hip joint with no adverse outcomes. One patient in the MRI cohort (without PAI) developed osteonecrosis of the femoral head. Conclusions We found lower sensitivity and specificity and higher false-positive rates for the Rosenfeld criteria in the hip for our geographically distinct population. Using the Rosenfeld criteria, MRIs would have been ordered unnecessarily in half of our series. Because of potential differences in regional microbiology and anatomic-specific factors, general predictive criteria for coexisting PAI based a single geographic region may be less generalizable to cases of hip sepsis in other geographic areas such as the Northeastern United States. Level of evidence Level 4-retrospective cohort study.

Background: Operative treatment of medial epicondyle (ME) fractures can be performed in either supine or prone position. In the supine position, visualization and fixation of the fracture is difficult. However, the prone position requires extensive patient repositioning but may improve visualization. Purpose: The purpose of this study was to compare the results of ORIF of ME fractures between supine and prone positions. Methods: In a retrospective review, patients Results: 204 patients were included, with a mean age of 11.7 years. 133(65.1%) were sports injuries, and 67(32.8%) had concomitant dislocation, with 17(8.3%) having an incarcerated fracture. 122(60%) patients were in the supine group, and 82(40%) in prone. The mean wheels in-wheels out time was 113 minutes in the supine group, and 141 minutes in the prone group (PConclusion: With the largest study population in the literature, the results of our study show that surgical stabilization of medial epicondyle fractures is safe, with minimal complications. While the prone position requires additional time in the operating room, presumably for positioning, the surgical procedure takes the same time and the prone position allows for a more accurate reduction. While the clinical significance of a 1mm difference in reduction quality is unknown, the observation that no surgeon that has tried the prone position had ever gone back to the supine position suggests that the surgical procedure is technically easier in this position.

Background:It remains unclear whether self-regulated exercise is sufficient to maintain the benefits acquired during formal cardiac rehabilitation (CR). This retrospective observational study investigated the effects of a home-based exercise intervention after discharge from CR upon anthropometric and aerobic capacity markers in clinically stable patients.Methods:Fifty patients with cardiovascular disease were discharged after 6 months of CR and encouraged to maintain aerobic exercise without supervision. Subsequent to 6 months of follow-up, patients were assigned to compliant (n = 34) or noncompliant (n = 16) groups according to their compliance to the home-based program. Maximal aerobic capacity (VO2peak) and anthropometric data were assessed before CR, at discharge, and after 6 months of follow-up.Results:No statistical differences between compliant and noncompliant groups were observed at baseline and at discharge from CR. At the end of the follow-up, statistical differences across groups were not found for body mass or body mass index, but increases in VO2peak (+3.6 vs. –0.6 ml/kg·min, P = 0.004) and oxygen pulse (+1.5 vs. +0.2 ml/bpm, P = .03) were greater in compliant than noncompliant group.Conclusions:Self-regulated exercising following CR discharge seems to be effective to maintain gains in exercise capacity acquired during supervised center-based programs.

Purpose To study the cause, diagnosis, treatment and outcome of acute compartment syndrome in infants and toddlers aged Methods Fifteen patients aged Results Nine (60 %) of fifteen patients developed compartment syndrome secondary to trauma, four (4/15, 27 %) due to infection, and two (2/15, 13 %) due to intravenous infiltration. The average time from injury or hospital admission to fasciotomy was 31.8 h (range 2.9–136.3 h). In general, the functional outcome was excellent at the latest follow-up with thirteen (13/15, 87 %) patients having an excellent outcome. No cases of Volkmann's ischemia were noted at the time of fasciotomy, even when performed as late as 5 days after injury. Conclusions Compared to the general pediatric population, the diagnosis of compartment syndrome in infants and toddlers may be further delayed, i.e., >24 h after injury. Despite delays in diagnosis and time to treatment, the present study shows that outcomes in infants and toddlers remain favorable even when fasciotomy is performed 48–72 h after injury. Level of evidence Case series, level IV.

There is uniform agreement in the literature that radial neck fracture with

Background: Congenital heart disease in adults shares some features with heart failure (HF), including exercise intolerance, ventilatory inefficiency, inflammatory and neurohormonal activation, cardiac arrhythmias and myocardial fibrosis. Over the last years, cardiopulmonary exercise test has gained importance in the diagnostic and prognostic evaluation of congenital heart diseases, as has already occurred in HF. Objective: To describe the behavior of hemodynamic, metabolic and ventilatory parameters in response to exercise in adults with congenital heart disease. Methods: Observational cross-sectional study evaluating 31 adults with congenital acyanotic or cyanotic heart disease, treated clinically, surgically or percutaneously, referred for cardiopulmonary exercise test. A descriptive analysis of the data was performed. Results: Patients aged 35.7 ± 14.2 years were included. Oxygen consumption (VO2) was 44.86 ± 18.01% of predicted at peak exercise and 36.92 ± 12.93% of predicted maximal VO2 at anaerobic threshold. We found an oxygen uptake efficiency slope (OUES) of 1.49 ± 0.89 (61.43 ± 26.63% of predicted), oxygen pulse of 58.90 ± 22.24% and increment in systolic arterial pressure during exercise was 31.42 ± 21.60 mmHg. Conclusion: Adults with congenital heart disease had similar responses to heart failure patients during exercise – reduced aerobic capacity, ventilatory inefficiency for oxygen consumption and limited inotropic response to exercise, characterized by reduced oxygen pulse and small increase in systolic arterial pressure.

Optimal management for a pulseless supracondylar humerus fracture associated with anterior interosseous nerve (AIN) or median nerve injury is unclear. The purpose of this study was to determine the incidence of pulseless supracondylar humerus fractures associated with AIN or median nerve injury, to assess open versus closed surgical management, to determine factors associated with the need for neurovascular intervention, and to report the outcome.A retrospective review was performed at 4 pediatric trauma hospitals on all patients who sustained a Gartland III or IV supracondylar humerus fracture with the combination of absent distal palpable pulses and AIN or median nerve injury between 2000 and 2014. Choice of treatment, details regarding preoperative and postoperative exam findings, follow-up course, and outcome were recorded.A total of 71 patients met inclusion criteria; 52 patients (73%) underwent closed reduction (CR); 19 patients (27%) underwent open reduction (OR) and early antecubital fossa exploration. The index procedure of CR plus percutaneous pinning was sufficient treatment in 50 (of 52, 96%) patients with only 2 requiring reoperation. One patient developed compartment syndrome approximately 9 hours after CRPP (13.5 h after time of injury) and underwent emergent fasciotomies. Of the 19 patients who underwent OR and early exploration, 6 needed vascular procedures, 5 required detethering of entrapped surrounding fibrous tissues. Forty patients were diagnosed with median nerve palsy versus 31 diagnosed with AIN palsy. There was no significant difference between patients presenting with median nerve versus AIN palsy, with similar rates of need for OR (10/40; 25% vs. 9/31; 29%), rate of compartment syndrome (3/40; 7.5% vs. 3/31; 9.7%), need for reoperation (4/40; 10% vs. 6.5%), and ultimate resolution of nerve palsy (4/36; 20.1% vs. 3/30; 10%). Compartment syndrome developed in 6 (of 71, 8.5%) patients and was associated with poor perfusion status on presentation and delayed time from injury to surgery. In patients with at least 3-month neurological follow-up, 59 (of 61, 97%) patients had complete resolution of nerve palsy.Although previous authors have suggested a pulseless SCH fx with an associated AIN or median nerve injury should be treated with exploration and OR, 70% (50/71) of the patients in this series were treated with a CR. In this series, both AIN and median nerve palsies among patients presenting with pulseless extremity and Gartland III or IV SCH fracture, offer similar rates of OR, risk of compartment syndrome, and resolution of nerve palsy.Level IV.

Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting.This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups.Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023).TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN.Level III, this was a retrospective comparative study.

Background Multiple hereditary exostoses (MHE) is an autosomal dominant condition leading to development of osteochondromas throughout the body. Although long bones are most often affected, spine involvement may occur and usually requires advanced imaging for diagnosis. However, the high cost of detection, infrequent occurrence, and very low likelihood of spinal cord compression and neurological injury, create a management conundrum. The purpose of our investigation is to identify patients at greatest risk for spinal lesions and refine indications for advanced imaging. Methods All MHE patients in a 24-year period were retrospectively reviewed. Skeletally immature patients with advanced imaging of the spine were further evaluated. The demographic characteristics, family history, clinical presentation, past surgical history, tumor burden, and distribution of patients with spinal lesions were compared with those without. Results In total, 227 MHE patients were identified and 21 underwent advanced spinal imaging. Spinal lesions were found in 8 of the 21 screened patients (38.1%, 3.5% overall), of which 4 were intracanal and 1 was symptomatic (4.8%, 0.4% overall). Only the symptomatic patient underwent excision of the spinal lesion. Patients with spinal lesions had higher tumor burden than those without (median, 28.5 vs. 19 locations; P=0.010). There was a significant association with rib (P=0.018) and pelvic (P=0.007) lesions, which may serve as "harbinger" lesions. The presence of both a rib and a pelvic lesion used as a screening tool for spinal lesions produces a sensitivity of 100% and specificity of 69%. Conclusions Symptomatic spinal involvement in children with MHE is rare and tends to occur in patients with higher tumor burden. We recommend limiting advanced spine imaging to children with neurological symptoms or with rib and pelvic "harbinger" lesions. Patients without these findings are unlikely to have spine involvement needing intervention. This approach offers an opportunity to avoid unnecessary testing and substantially reduce costs of diagnostic imaging. Level of evidence Level III.

Total body irradiation (TBI) is commonly used in conditioning regimens for allogeneic hematopoietic stem cell transplantation (HSCT) to treat benign and malignant disease. Though life-saving, these therapies place patients at risk for important side effects, including musculoskeletal complications such as short stature, osteonecrosis, slipped capital femoral epiphysis, and the development of benign and malignant bone tumors. With an increasing number of HSCT survivors, there is a growing need for awareness of the musculoskeletal complications of HSCT and TBI.