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Background: The initial diagnosis of capitellum osteochondritis dissecans (OCD) is typically confirmed using standard anteroposterior (AP) and lateral elbow radiographs, despite low sensitivity, which is approximately 44-47%. An AP image of the elbow in 45° of flexion has been suggested to increase diagnostic accuracy. Purpose: To assess the diagnostic performance, inter- and intra-observer reliability, and confidence level for identifying capitellum OCD using plain radiographs (AP, lateral, and 45° flexion AP) in pediatric and adolescent patients. Methods: This was a retrospective study including pediatric and adolescent patients with capitellum OCD and a healthy control group. Independent clinicians were blinded to the official radiologists’ reports and reviewed images on a picture archiving and communication system on two separate occasions 1 week apart. A 5-point Likert scale was used to assess the clinicians’ level of confidence (1-not at all confident; 5-very confident). Inter- and intraobserver reliability was determined using kappa statistics. Results: The study included 28 elbows (24 patients) with a mean age of 12.5 ± 2.0 years. 64.3% were female. There were no differences in age ( P = 0.18), sex ( P = 0.62), or laterality ( P = 1.0) between the two groups. There were marked variations in the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each of the following views: AP: Sensitivity 85.1; Specificity 89.3; PPV 88.8; NPV 85.7; accuracy 87.2. Lateral: Sensitivity 73.2; Specificity 91.7; PPV 89.8; NPV 77.4; accuracy 82.4. 45° flexion AP: Sensitivity 91.7; Specificity 91.1; PPV 91.1; NPV 91.6; accuracy 91.4. Standard radiographs (AP and lateral views) failed to diagnose capitellum OCD in 4.8% of cases. The sensitivity of the three combined views was 100%. Confidence levels in the clinicians’ diagnostic assessments were similar for each view (AP, 4.0; lateral, 4.0; and 45° flexion AP, 4.1). Interobserver reliability was substantial for AP and lateral views (k=0.65 and k=0.60, respectively) but highest for the 45° flexion AP radiographs (k=0.72). Intraobserver reliability for all views was moderate to perfect (k=0.52 to 0.93). Conclusion: The 45° flexion AP view can detect capitellum OCD with excellent accuracy, a high level of confidence, and substantial interobserver agreement. When added to standard AP and lateral radiographs, capitellum OCD can be diagnosed in 100% of cases.

Objective Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. Study design Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. Results 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. Conclusion At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Purpose Paediatric hand injuries are a frequent reason for acute medical evaluation. Previous studies have reported only fracture rates, surgical injuries or are limited to database diagnosis coding. The average fracture rates and injury distributions across the hand for all mechanical injuries have not been well-described. Methods We performed a retrospective review of all emergent/urgent care visits over 18 months at a US paediatric tertiary hospital with hand injuries recorded anywhere in the encounter. Patient, injury and encounter details were recorded with additional imaging review, categorized and described. Results A total of 523 patient visits (0.64% of all encounters) were for mechanical hand trauma. The injury mechanism was 42% crush, 19% jammed, 12% impact, 12% fall on outstretched hand, 7% hyperextension and 8% other/unclear. Crush was responsible for 80% of injuries in patients aged 0 to six years old but only 17% in patients aged 13 to 18 years. Crush resulted in fractures only 26% of the time, while other mechanisms were more likely to fracture (33% to 87%). Border digits were injured more often than others (21% to 23% versus 13% to 17%), and were most commonly fractured in the proximal phalanx (57% to 67% versus 22% to 34% for non-border digits). Providers correctly coded for basic fracture presence in 89.1% of injuries, but 53% of codes were not finger or laterality-specific, and only 15% specified a bony segment demonstrating that International Classification of Diseases-9 coding was nonspecific for injury patterns. Conclusion Patients with paediatric hand injuries frequently utilize emergency care and understanding the basic patterns of injury can guide resource utilization and future studies on optimal treatment algorithms in this setting. Level of Evidence IV, Prognostic, Case Series

Background:Many treatment options exist for unicameral bone cysts (UBC), without clear evidence of superiority. Meta-analyses have been limited by small numbers of patients in specific anatomic and treatment subgroups. The purpose of this study was to report the outcomes of injecting bone marrow aspirate and demineralized bone matrix (BMA/DBM) for the treatment of proximal humerus UBC.Methods:Fifty-one patients with proximal humerus lesions treated by BMA/DBM injection were retrospectively reviewed from a single academic medical center.Results:The mean number of injections performed per patient was 2.14 (range 1-5). Eleven patients underwent only one injection (22%), an additional 19 patients completed treatment after two injections (37%), four patients healed after three injections (8%), and one patient healed after four injections (2%). The cumulative success rate of serial BMA/DBM injections was 22% (11/51), 58% (30/51), 67% (34/51), and 69% (35/51). Eleven patients (22%) ultimately underwent open curettage and bone grafting, and five patients (10%) were treated with injection of calcium phosphate bone substitute.Conclusion:A BMA/DBM injection strategy avoided an open procedure in 78% of patients with a proximal humerus UBC. The majority of patients underwent at least 2 injection treatments.Level of Evidence:Level IV retrospective cohort study.

Background Injury prevention programs have been shown to be effective for adolescent soccer, basketball, and handball athletes. Though injuries are common in high school runners, injury prevention programs have not been described for this population. Our objective was to trial an injury-prevention program styled after those found to be successful in other running and jumping sports to see if a group of running athletes sustained fewer and or less serious injuries during the course of a single high school track season. Methods Two suburban high school track coaches volunteered to participate in a program consisting of either injury-prevention exercises or no additional exercises as a part of pre-and in-season practice programs. All runners at each school were invited to participate, with informed consent obtained. The injury prevention program consisted of five jumping and plyometric exercises taught by a physical therapist, with a video of the exercises made available to the coach and team members throughout the season. Surveys pre- and post-season were collected which included demographic information, running history, diet, and injuries. Injuries were reported to coach and trainer at each school. Days of missed practice constituted an injured day, tallied for each runner and each team. A Chi-square analysis compared injury rates by team, and hence by intervention; injury rates by years of experience running; and injury rates by dietary preference. Results 24 runners, 13 from the intervention school and 11 from the control school participated. There was no significant difference in the number of running injuries reported when comparing the intervention group (4/13 runners) to the control group (3/11 runners, Chi-square = 0.035, p = 0.9). Runners with a greater number of years of competitive running experience trended towards having fewer injuries (p = 0.06). Those describing their diet as vegetarian (3/24) were significantly more likely to sustain an injury (p = 0.002). Conclusions / Significance With this limited comparison study examining the impact of an injury-prevention pre-season and in-season training program for running athletes participating on their high school track team, there was no evidence that the addition of a program of jumping and plyometric exercises had an impact on injury rates. However, combining the data from the two schools, we found a trend towards decreased injury likelihood in those with more years of experience running, and a significantly greater incidence of injuries in those who described their diet as vegetarian. These results suggest that novice runners should perhaps have a different set of expectations regarding the pre- and in-season training regimen, and that those whose diet is vegetarian consider review of their nutrition to optimize their energy level and reparative capacity with the increased activity of a high school track running program.

BACKGROUND Return-to-Sport (RTS) after knee surgery involves the return of strength and dynamic knee stability, which can be assessed with isometric strength and functional performance testing. There is little evidence-based data to assist with RTS decision-making after meniscus repair. Furthermore, there is limited RTS data comparing patients with discoid meniscus tears and instability from those with non-discoid tears. The purpose of this study was to compare the performance on functional RTS tests between pediatric patients with discoid and non-discoid meniscus tears. METHODS A retrospective review was performed of pediatric patients that underwent isolated meniscus repair by a single pediatric orthopaedic surgeon from 2010-2016. Thirty patients (14 discoid, 16 non-discoid) were identified who underwent a postoperative RTS assessment consisting of isometric strength testing, the Lower Quarter Y-balance Test (YBT-LQ), and single-leg hop testing (single hop for distance, triple hop for distance, crossover triple hop for distance, and timed hop). Demographic information and RTS data were compared between groups. Recovery of muscle strength was defined by a limb symmetry index (LSI) =90%. Statistical significance was set at P = 0.05. RESULTS The mean age of the patients was 13.95 years (range, 8-19 years). Patients in the discoid group were younger than those with non-discoid meniscus tears (12.9 vs 15.1 years, respectively) (P =0.05). There was a statistically significant difference in the average time from surgery to RTS test between the discoid (269 days) and non-discoid (184 days) groups. (P =0.02). For isometric strength testing, both groups had mean LSIs greater than 90% for quadriceps, hamstring, and hip abduction. There were no statistically significant differences between groups in isometric strength or performance on the YBT-LQ or any of the single-leg hop tests. CONCLUSIONS Pediatric patients who undergo repair of a discoid meniscus may require prolonged rehabilitation to achieve satisfactory completion of RTS testing. In our study, an additional 3 months on average were required to allow adequate recovery of muscle strength and dynamic functional stability when compared to those with a non-discoid meniscal repair. However, upon completion of a structured physical therapy program with stringent RTS guidelines, at the time of testing, there was no significant difference in performance on any of the RTS tests between patients with discoid and non-discoid meniscus tears. The findings of this study can assist orthopedic surgeons in safely returning pediatric patients back to sporting activities following meniscus repair.

We present two siblings affected with opsismodysplasia (OPS), a rare skeletal dysplasia caused by mutations in the inositol polyphosphate phosphatase-like 1 gene. The skeletal findings include short stature with postnatal onset micromelia, marked platyspondyly, squared metacarpals, delayed skeletal ossification, metaphyseal cupping, and postnatal micromelia. Respiratory compromise, delayed ambulation, and progressive lower extremity deformities are described. The severity of findings is variable. Renal phosphate wasting is associated with severe bone demineralization and a more severe phenotype. This report represents the first described cases of opsismodysplasia treated with intravenous bisphosphonate (pamidronate). Surgical management for lower extremity deformities associated with OPS is also reviewed. Level of Evidence: IV Case series

Background: The goal of the study was to evaluate the efficacy of physical therapy in restoring function and mobility after a pediatric supracondylar humeral fracture. Methods: The study included sixty-one patients from five to twelve years of age with a supracondylar humeral fracture that was treated with casting or with closed reduction and pinning followed by casting. Patients were randomized to receive either no further treatment (no-PT group) or six sessions of a standardized hospital-based physical therapy program (PT group). The ASK-p (Activities Scale for Kids-performance version) and self-assessments of activity were used to assess function at one, nine, fifteen, and twenty-seven weeks after injury. Motion was measured at nine and fifteen weeks after injury by a blinded therapist. Anxiety was measured at one and nine weeks after injury with a self-assessment. Differences in ASK-p scores and anxiety level were analyzed with use of multivariate generalized estimating equations. Results: ASK-p scores were significantly better in the no-PT group at nine and fifteen weeks after injury (p = 0.02 and 0.01, respectively) but the difference at twenty-seven weeks was not significant. There were no differences between groups with respect to performance of activities of daily living or time to return to sports. Anxiety at nine weeks was associated with worse ASK-p scores at nine and fifteen weeks in the PT group and with better ASK-p scores in the no-PT group at these time points (p = 0.01 and 0.02, respectively). There were no differences between the groups with respect to elbow motion in the injured arm at any time. Severity of injury had no impact on function or elbow motion in either the PT or the no-PT group. Conclusions: Children undergoing closed treatment of a supracondylar humeral fracture that was limited to approximately three weeks of cast immobilization received no benefit involving either return of function or elbow motion from a short course of physical therapy. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background ACL injuries in preteens and teens are common occurrences. Reconstruction is believed to be optimum treatment for those wishing to return to running, cutting, and jumping sports. Rates of reoperation, satisfaction, and long-term return to and maintenance of preinjury activity after ACL reconstruction in young athletes are important information for physicians, patients, and parents.

Context: The Lystedt law requires high school athletes who have sustained a concussion to be removed from practice and play and not to be allowed to return until cleared by a medical professional. Objective: To determine the effect of the Lystedt law on injury and concussion documentation in the Seattle public high schools. Design: Cross-sectional study. Setting: Seattle public high schools. Patients or Other Participants: The numbers of students, aged 13 to 19 years in the 2008–2009, 2009–2010, and 2010–2011 school years, were 4348, 4925, and 4806, respectively. Main Outcome Measure(s): All injuries documented in SportsWare by athletic trainers in Seattle public high schools. We evaluated all injuries, including concussions recorded during the 2008–2009 school year, before the Lystedt law, and during the 2 school years after the law took effect (2009–2010 and 2010–2011). Incidence rates before and after the law were estimated and compared. Results: The concussion rate was −1.09% in 2008–2009, 2.26% in 2009–2010, and 2.26% in 2010–2011. A comparison of relative risks showed that the incidence rates of concussions were different before and 1 year after the Lystedt law (relative risk = 2.10; 95% confidence interval [CI] = 1.50, 2.93) and 2 years after the law (relative risk = 2.10; 95% CI = 1.49, 2.93). Overall, the mean number of days out of play after 2008–2009 was almost 7 days greater after the law took effect (difference = 6.9 days; 95% CI = 0.70, 13.1). For females, the mean number of days out of play after 2008–2009 was more than 17 days in 2009–2010 (difference = 17.2 days; 95% CI = 4.81, 29.5) and was more than 6 days in 2010–2011 (difference = 6.3 days; 95% CI = 1.62, 11.0). Conclusions: The number of documented concussions more than doubled after the institution of the Lystedt law, which may be attributed to heightened awareness and closer monitoring.

Background Reported complications of pediatric septic arthritis range from minor growth abnormalities to potentially life-threatening conditions and death; some children require multiple surgeries for eradication of infection. The purpose of this study is: (1) to determine the failure rate of a single surgical incision and drainage (I&D) in pediatric septic arthritis, (2) to identify risk factors for failure which are detectable at the time of initial presentation, and (3) to trend post-operative C-reactive protein (CRP) values to see if there is a difference between children who fail a single I&D and those who do not. Methods The medical records for 105 children who underwent operative management of septic arthritis were retrospectively reviewed. Single and multivariate analyses were performed. Results Eighty-four children required one surgical intervention [mean age 5.18 years (±4.01); 38 females (45 %), 46 males (55 %)], 21 children required revision surgery [mean age 8.16 years (±4.54); 4 females (19 %), 17 males (81 %)], and the overall rate of revision surgery was 20 %. Delayed diagnosis ( p = 0.015), elevated CRP at presentation ( p = 0.000), positive blood culture ( p = 0.000), and age ( p = 0.009) were all associated with revision surgery in bivariate analysis. In multivariate analysis, CRP at presentation and positive blood culture were significant risk factors for revision surgery ( p = 0.005 and p = 0.025, respectively). Additionally, markedly elevated CRP levels on post-operative days (POD) 1–4 were each independently significant risk factors for requiring multiple surgeries (all p < 0.000). Fever, elevated erythrocyte sedimentation rate, and leukocyte count were not risk factors for multiple surgeries. Conclusions In this study, a positive blood culture or marked elevation in CRP at presentation or on POD 1–4 were associated with revision surgery. These findings may help improve surgical planning for both the initial surgery in order to avoid revisions, as well as revision surgery, should it be indicated. Level of evidence III.

Purpose To test the hypothesis that collecting material for culture from metaphyseal bone of the ilium and proximal femur at the time of a hip aspiration will increase the sensitivity to detect an infectious organism in patients with presumed septic arthritis of the hip. Methods We retrospectively reviewed a series of 36 patients with presumed septic arthritis of the hip, based on clinical exam and serum inflammatory markers, who underwent aspirations of hip synovial fluid as well as blood from the ilium and proximal femur. Culture results from aspirates of synovial fluid and bone and tissue from capsule were compared to determine the sensitivities and specificities of a synovial aspirate alone versus synovial aspirate plus aspirates of the ilium and proximal femur to detect infection. Results The sensitivity of hip synovial fluid aspirates to detect infection via positive culture was only 63 %, though this increased significantly to 100 % when the results of cultures of aspirates of the ilium and proximal femur were included. The specificities were equivalent in both modalities (≥90 %). We conclude that obtaining aspirates of the ilium and proximal femur at the time of hip synovial fluid aspiration increases the likelihood that the procedure will return an infectious organism. Conclusion Positive cultures from a child with a septic hip or peri-articular hip infection help to efficiently and effectively guide antibiotic treatment. The child with a septic hip or peri-articular hip infection and positive cultures is likely to receive more narrow-spectrum therapy, potentially decreasing the overuse of broad-spectrum antibiotics. Level of evidence: Diagnostic study level III Development of diagnostic criteria on the basis of a series of non-consecutive patients (with universally applied reference “gold standard”).