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Background: Type I tibial spine fractures are non-displaced or minimally displaced (≤ 2mm displacement) fractures of the tibial eminence and ACL insertion traditionally managed nonoperatively with immobilization. Hypothesis/Purpose: We hypothesized that type I fractures do not carry significant risk of associated injuries and therefore do not require additional interventions aside from immobilization. Methods: We reviewed 52 patients classified by their treating institution with type I tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients of age ≤ 18 years with pre-treatment plain radiographs and at least one year of follow-up were included. Data was collected on patient demographics, injury mechanism, treatment details, presence of concomitant injuries, range of motion (ROM) at final follow-up, treatment complications, and any return to the operating room for the injured knee. Pre-treatment imaging was reviewed by four authors to assess agreement of classification among the treating institutions. Patients were subclassified into two groups to ensure outcomes represented classic type I fracture patterns. Any patient with universal agreement among the four authors that the fracture did not appear consistent with a type I classification were assigned to Type 1+ Group (T1+). All other patients were assigned to the True Type I Group (TT1). We evaluated concomitant injury, need for operative intervention, and treatment outcomes overall and for each group independently. Results: 48 patients met inclusion criteria. 40/48 were TT1 fractures, while 8/48 were T1+ fractures, indicating less than universal agreement among sports specialists in classification of these fractures. Among TT1 patients, 7 of 40 (18.4%) underwent surgical treatment, though this represented 35.7% (5/14) of those who had undergone pretreatment advanced imaging. In the T1+ group, 6 of 8 (75%) underwent surgical treatment, 50% of whom (3/6) had pretreatment advanced imaging. Overall, twelve of 48 patients (25%) had concomitant injuries, nine TT1 patients and three T1+ patients (p=0.77), with 7 concomitant injuries requiring additional surgical management. Conclusions: Classification of type I fractures can be challenging. Nonetheless, a substantial percentage of patients with these fractures (>20%) were found to have concomitant injuries by advanced pretreatment imaging, with surgical management indicated in 58.3% of these patients. Contrary to traditional thought, type I tibial spine fractures do carry a risk of associated injuries. Simple cast immobilization may not be the ideal treatment in all cases. Advanced imaging would be beneficial for those whose plan of care may initially be non-operative treatment. [ABSTRACT FROM AUTHOR]

Background: The uncommon nature of tibial spine fractures may result in delayed presentation, diagnosis, and treatment. Elucidation of the contributing factors to such delays may provide an opportunity to improve patient care. Additionally, the outcomes of delayed surgery are unknown. Hypothesis/Purpose: The purpose of this study is to evaluate risk factors for, and consequences of, delayed surgical treatment of pediatric tibial spine fractures. Methods: We performed a retrospective cohort study of tibial spine fractures treated surgically at 10 institutions between 2000 and 2019. Demographic and pre-operative data were collected, as was intra-operative information and post-operative complications. Attention was focused on delays in evaluation and treatment, which were treated as both continuous and categorical variables. Surgery ≥21 days after injury was considered "delayed". Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: A total of 368 subjects (mean age 11.7±2.9 years) were included, 21.2% of which underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF 1 or more weeks after injury [95% confidence interval (CI) 1.1-14.3, p=0.04], 2.3 times higher odds of having seen multiple clinicians prior to the treating surgeon (95% CI 1.1-4.8, p=0.02), 5.8 times higher odds of having magnetic resonance imaging 1 or more weeks after injury (MRI; 95% CI 1.6-20.8, p<0.007), and were 2.4 times more likely to have public insurance (95% CI 1.3-4.2, p=0.003). Meniscal injuries were encountered intra-operatively in 42.3% of those that had delayed surgery compared to 16.6% of patients that did not (p<0.001), resulting in 2.8 times higher odds in multivariate analysis (95% CI 1.6-5.0, p<0.001). Delayed surgery was also a risk factor for procedure duration longer than 2.5 hours (odds ratio 3.3, 95% CI 1.4-7.9; p=0.006). Patients who experienced delayed surgical management and an operation longer than 2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI 1.1-12.5, p=0.03). Conclusion: When surgery for a TSF was performed ≥21 days after injury, patients were at increased risk for concomitant meniscal pathology, longer case duration, and possibly post-operative arthrofibrosis. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery. These results provide an opportunity to optimize care for children that are at highest risk for delayed treatment. [ABSTRACT FROM AUTHOR]

Background: Stress fractures are a common overuse injury in the pediatric population. Distal fibular and calcaneal stress fractures are considered low-risk stress fractures. Due to their rarity, they have not been studied as thoroughly as other stress fractures. Purpose: To present a descriptive case series of distal fibular and calcaneal stress fractures in the pediatric population and elaborate on demographics, mechanism of injury, management and outcomes. Methods: IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a distal fibular or calcaneal stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, and outcomes were collected. Descriptive statistical analysis was conducted. Results: 11 patients, 6 distal fibula (4 female, 2 male) and 5 calcaneus (2 female, 3 male) with stress injury on clinical exam and on X-ray or MRI were included. Mean age was 11 years (1-15) and average BMI of 23.5 (16-30.7). The common presenting complaint was pain aggravated by activity that began an average of 3 weeks prior. 7/11 (63.6%) participated in competitive sports: 4/6 with fibular stress fractures were runners (cross country, soccer and sprinting) compared to 0/5 patients with calcaneal involvement. Typical radiographic findings (periosteal reaction, cortical thickening) and a corresponding physical exam was sufficient to diagnose fibular stress fractures in 5/6 patients, with one requiring MRI for definitive diagnosis. 4/5 patients with calcaneal stress fractures required an MRI for a definitive diagnosis, delaying the diagnosis by an average of 3 weeks. 5/6 patients with fibular stress fractures had no other associated pathology, such as additional stress fractures, bone cysts, or osteoid osteomas, whereas 3/5 with calcaneal injuries had at least one of these associated pathologies. Patients with isolated fibular or calcaneal stress fractures (7/11) improved with conservative management, including a controlled ankle motion (CAM) boot, PT, and full activity rest over an average of 6.5 weeks. Out of the remaining 4 patients with associated pathologies, 3/4 improved with conservative management alone after an average of 20 weeks; however, one patient required surgical removal of a bone cyst before complete recovery. Conclusion: A history of pain with significant running, X-ray findings, and physical exam findings were sufficient for diagnosis of fibular stress fractures; however, calcaneal stress fractures were often occult, requiring MRI for definitive diagnosis, and were associated with other pathologies. Conservative management was sufficient for treatment of 91% of patients, regardless of additional fractures or pathology. Fig. 1 Right Ankle X-ray, AP view - Periosteal reaction along the distal right fibular diaphysis, a common finding when stress fractures are found on radiographs. Fig. 2 Left Ankle STIR MRI, sagittal view - Hypointense line through the metaphysis of the calcaneal tuberosity, indicative of a stress fracture. There is surrounding hyperintense marrow edema throughout much of the calcaneus as well. [ABSTRACT FROM AUTHOR]

Background: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature on discoid medial menisci is limited, with few reported cases in children. Purpose: To report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. Methods: A retrospective review of medical records including operative reports was performed to identify patients diagnosed with a discoid medial meniscus confirmed via direct surgical observation across eight children's hospitals between January 2000 and March 2020. Results: Twenty-one patients (9 female, 12 male) with 22 discoid medial menisci were identified, one with bilateral discoid medial menisci. The mean age at time of diagnosis was 12.7 years (range, 3-18 years). One patient had discoid medial and discoid lateral menisci in the same knee. The most common symptoms and signs of patients with a discoid medial meniscus were locking and/or clunking, present in over 50% of patients. Twelve discoid medial menisci were complete (55%), 8 were incomplete (36%), and two were indeterminate (9%). Tears were present in 13 knees. Of those with tears, 7 were horizontal tears (4 posterior, 1 anterior, and 2 mid-body), 5 were complex (3 posterior, 1 anterior, and 1 mid-body), and 1 was a posterior vertical tear. Five of these discoid medial menisci were unstable (23%). The average time between initial diagnosis and treatment was 13 months (range, 0-121 months). All knees underwent arthroscopic saucerization, and of the 13 torn discoid medial menisci, 7 were repaired (54%). The mean length of clinical follow-up postoperatively was 24 months (range, 1-82 months). Four of these discoid medial menisci underwent re-operation, most commonly for persistent symptoms. All knees which required re-treatment initially presented with a tear, all of which had been repaired. There was a significant association between initial presence of a tear and need for re-operation, [χ2 = 4.1, p = 0.044]. Conclusions: In this multicenter study of patients treated for a discoid medial meniscus, symptoms and signs at presentation and findings at arthroscopy were similar with those commonly seen in patients with a discoid lateral meniscus. Tears were present in more than half of knees, and reoperation was more common in knees identified with tears of their discoid medial menisci than those without tears. Future studies should seek to determine the long-term functional and patient-reported outcomes following treatment of discoid medial menisci. [ABSTRACT FROM AUTHOR]

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation. Hypothesis/Purpose: We hypothesized both approaches can lead to satisfactory outcomes for fracture healing, but that open treatment without preoperative advanced imaging can potentially lead to missed concomitant injuries. Methods: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into two cohorts based on treatment: arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF). Surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared to those treated with ORIF (24.6%, p=0.021). Patients treated with ARIF were also more likely to have pre-treatment MRI (41.7% vs. 22.8%, p =0.010). Most concomitant injuries (74.5%) required surgical intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, p=1.00) and subsequent ACL injury (2.1% in ARIF patients and 3.5% in ORIF, p=0.86). The rate of complications, return to the operating room, and failure to return to full range of motion were similar between groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This is the largest study comparing ARIF to ORIF in pediatric tibial spine fractures. This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF for pediatric tibial spine fractures. There were significantly higher rates of concomitant injuries in patients treated with ARIF, however, these patients also had a higher rate of pre-treatment MRI. The majority of these concomitant injuries (74.5%) required surgical intervention. Pre-treatment MRI should be considered in the workup of tibial spine fractures to increase identification of concomitant injury. Concomitant injuries may be missed in tibial spine fractures treated with an open approach, especially in cases where preoperative advanced imaging is not obtained. Surgeon preference and training may impact treatment approach and identification and treatment of concomitant injury. [ABSTRACT FROM AUTHOR]