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BACKGROUND: There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury. METHODS: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Physicians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule. RESULTS: Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding '[greater than or equal to] 4 episodes of vomiting' resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury. INTERPRETATION: Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact., Pediatric head injury accounts for more than 500 000 emergency department visits annually in the United States. (1) Most head injuries are mild and do not require neurosurgical management. However, [...]

Because number-based standards are increasingly controversial, the objective of this study was to derive a performance-based competency standard for the image interpretation task of point-of-care ultrasound (POCUS).

Objective: This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth. Methods: A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5–18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models. Results: 2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)]. Conclusions: Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

Background: The Low Risk Ankle Rule is a validated clinical decision rule that has the potential to safely reduce radiography in children with acute ankle injuries. We performed a phased implementation of the Low Risk Ankle Rule and evaluated its effectiveness in reducing the frequency of radiography in children with ankle injuries. Methods: Six Canadian emergency departments participated in the study from Jan. 1, 2009, to Aug. 31, 2011. At the 3 intervention sites, there were 3 consecutive 26-week phases. In phase 1, no interventions were implemented. In phase 2, we activated strategies to implement the ankle rule, including physician education, reminders and a computerized decision support system. In phase 3, we included only the decision support system. No interventions were introduced at the 3 pair-matched control sites. We examined the management of ankle injuries among children aged 316 years. The primary outcome was the proportion of children undergoing radiography. Results: We enrolled 2151 children with ankle injuries, 1055 at intervention and 1096 at control hospitals. During phase 1, the baseline frequency of pediatric ankle radiography at intervention and control sites was 96.5% and 90.2%, respectively. During phase 2, the frequency of ankle radiography decreased significantly at intervention sites relative to control sites (between-group difference -21.9% [95% confidence interval [CI] -28.6% to -15.2%]), without significant differences in patient or physician satisfaction. All effects were sustained in phase 3. The sensitivity of the Low Risk Ankle Rule during implementation was 100% (95% CI 85.4% to 100%), and the specificity was 53.1% (95% CI 48.1% to 58.1%). Interpretation: Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely, without an accompanying change in physician or patient satisfaction. Trial registration: ClinicalTrials.gov, no. NCT00785876., Pediatric ankle injuries result in more than 2 million emergency department visits in Canada and the United States each year (Jeanette Tyas, Canadian Institute of Health Information: unpublished data, 2007). [...]

Background: Minimally angulated fractures of the distal radius are common in children and have excellent outcomes. We conducted a randomized controlled trial to determine whether the use of a prefabricated splint is as effective as a cast in the recovery of physical function. Methods: We included 96 children 5 to 12 years of age who were treated for a minimally angulated (≤ 15°) greenstick or transverse fracture of the wrist between April 2007 and September 2009 at a tertiary care pediatric hospital. Participants were randomly assigned to receive either a prefabricated wrist splint or a short arm cast for four weeks. The primary outcome was physical function at six weeks, measured using the performance version of the Activities Scale for Kids. Additional outcomes included the degree of angulation, range of motion, grip strength and complications. Results: Of the 96 children, 46 received a splint and 50 a cast. The mean Activities Scale for Kids score at six weeks was 92.8 in the splint group and 91.4 in the cast group (difference 1.44, 95% confidence interval [CI]-1.75 to 4.62). Thus, the null hypothesis that the splint is less effective by at least seven points was rejected. The between group difference in angulation at four weeks was not statistically significant (9.85° in the splint group and 8.20° in the cast group; mean difference 1.65°, 95% CI-1.82° to 5.11°), nor was the between-group differences in range of motion, grip strength and complications. Interpretation: In children with minimally angulated fractures of the distal radius, use of a splint was as effective as a cast with respect to the recovery of physical function. In addition, the devices were comparable in terms of the maintenance of fracture stability and the occurrence of complications. (ClinicalTrials.gov trial register no. NCT00610220.), Previously published at www.cmaj.ca Fractures of the distal radius are the most common fracture in childhood (1) and a frequent reason for visits to the emergency department. (2) Although such [...]

ABSTRACT Background: Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures. Objectives: The [...]

Abstract Background: The Greater Toronto Area (GTA) was considered a "hot zone" for severe acute respiratory syndrome (SARS) in 2003. In accordance with mandated city-wide infection control measures, the Hospital [...]

Supplemental digital content is available in the text.

Supplemental digital content is available in the text.

ObjectiveTo assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity.MethodsWe performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5–17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings.Results3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2–14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%–72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity.ConclusionPost-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.

Between February and September 2003 Health Canada reported 438 probable or suspect cases of severe acute respiratory syndrome (SARS) resulting in 43 deaths (1) primarily in the Greater Toronto Area [...]

In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs.

1 Low-risk ankle injuries are the most common lower-extremity injuries in children Low-risk injuries in the lower extremities among children include lateral ankle sprains and isolated nondisplaced distal fibular Salter-Harris [...]

A 12-year-old male injured his ankle while playing hockey (Figure 1). His dad reports that he was checked into the boards. His ankle is swollen, but does not appear deformed. His distal neurovascular exam is normal. There is bony tenderness over the lateral malleolus in accordance with the Ottawa Ankle Rules.

Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.

ObjectivesWe evaluated the association between timing of presentation and postconcussive symptoms (PCS) at 1, 4 and 12 weeks after injury.MethodsThis was a secondary analysis of a prospective cohort study conducted in nine Canadian paediatric EDs in 2013–2015 (5P study). Participants were children who suffered a head injury within the preceding 48 hours and met Zurich consensus concussion diagnostic criteria. The exposure was the time between head injury and ED presentation. The primary outcome was the presence of PCS at 1 week defined by the presence of at least three symptoms on the Post-Concussion Symptom Inventory (PCSI). Secondary outcomes evaluated PCS at 4 and 12 weeks. Multivariable logistic regression analyses were adjusted for ED PCSI and other potential confounders.ResultsThere were 3041 patients with a concussion in which timing of the injury was known. 2287 (75%) participants sought care in the first 12 hours, 388 (13%) 12–24 hours after trauma and 366 (12%) between 24 and 48 hours. Compared with children who sought care >24 hours after trauma, children who sought care in the first 12 hours had a significantly lower incidence of PCS at 1 week (OR: 0.55 (95% CI 0.41 to 0.75)) and 4 weeks (OR: 0.74 (95% CI 0.56 to 0.99)) but not at 12 weeks (OR: 0.88 (95% CI 0.63 to 1.23)).ConclusionsPatients who present early after a concussion appear to have a shorter duration of PCS than those presenting more than 12 hours later. Patients/families should be informed of the higher probability of PCS in children with delayed presentation.

Traumatic brain injury (TBI) is a major health problem in children. Blood-based biomarkers interpreted by use of normative values might improve the accuracy of diagnosis. Ultrasensitive assays can quantify serum concentrations of the neuronal microtubule-associated protein tau, which is increased in adult brains following TBI. We aimed to determine if serum total tau correlates with TBI diagnosis, severity, and radiological findings on CT scans in children younger than 18 years.

AbstractObjectiveOndansetron is increasingly administered to children suffering from concussion-associated nausea/vomiting. We examined the association between ondansetron administration and post-concussion symptoms in children at 1 week and 1 month following the concussion.MethodsThis was a secondary analysis of data collected prospectively in a cohort study conducted in nine pediatric emergency departments (EDs) (5P study). Participants were children ages between 5 and 17.99 years who sustained a concussion in the previous 48 hours. For the current study, only 5P participants who reported nausea and/or vomiting in the ED were eligible. The exposure of interest was ondansetron administration; the comparison group included all other participants. The primary outcome was an increase in at least three symptoms of the Post-Concussion Symptom Inventory score at 1 week and 1 month following trauma.ResultsAmong the 3,063 children included in the 5P study, 1805 (59%) reported nausea and provided data at 1 week and/or 1 month. Among them, 132 (7%) received ondansetron. Multivariable logistic regression adjusted for confounders did not show an association between ondansetron use and the risk of persistent post-concussion symptoms at 1 week (OR: 1.13 [95% CI: 0.86-1.49]), but it was associated with a higher risk at 1 month (OR: 1.33 [95% CI: 1.05-1.97]).ConclusionIn children presenting to the ED with an acute concussion, ondansetron use was associated with a higher risk of persistent post-concussion symptoms at 1 month. Although this may be related to the limitations of the design, it highlights the importance of evaluating this association using a randomized clinical trial.

Objective: To determine the rate of acetaminophen related nephrotoxicity in adolescents who present after acute severe acetaminophen intoxication and to identify potential predictors of this outcome. Study Design: Retrospective analysis of consecutive patients between the ages of 12 and 18 years who were admitted at a tertiary care children's hospital for treatment of acute severe acetaminophen intoxication with N-acetylcysteine. The main outcome measure was the frequency of acetaminophen-related nephrotoxicity, defined as abnormal blood urea nitrogen ([is greater than] 6.4 mmol/ L or [is greater than] 18 mg/dL) and/or elevated creatinine (97.2/[micro]mol/L or [is greater than] 1.1 mg/dL) in association with one or both of the following: elevated blood pressure (systolic blood pressure [is greater than] 140 mm Hg/diastolic blood pressure [is greater than] 85) or abnormal urinalysis (urinalysis with hematuria or proteinuria). Statistical analyses used were measures of central tendency, Student's t-test, Mann-Whitney, and multivariate logistic, regression. Results: Fourty-five patients were included. Acetaminophen-related nephrotoxicity occurred in 4 (8.9%) cases. One victim developed severe renal injury in association with elevated hepatic transaminases. Intergroup analyses revealed no statistically significant association between acetaminophen-related nephrotoxicity and amount/ kg of acute severe acetaminophen ingested, delay in treatment with N-acetylcysteine, or measures of hepatic function. Conclusions: Acetaminophen-related nephrotoxicity occurred in 8.9% [95% CI: 4.52, 20.48] of children with severe overdose. There are no obvious predictors of this complication of acetaminophen overdose. Because the occurrence of renal injury can not be predicted, serial blood pressure, blood urea nitrogen/creatinine, and urinalysis should be considered an integral part of the management of children with acute, severe acetaminophen intoxication., INTRODUCTION Hepatotoxicity after acetaminophen (APAP) intoxication has been well described in both children and adults (1-7). In contrast, acetaminophen-related nephrotoxicity (APAP/NT) in the absence of fulminant hepatic failure and/or hypotension [...]

1 Buckle fractures of the distal radius are common in children between 2 and 12 years of age Buckle (torus) fractures occur when the bony cortex is compressed and bulges, [...]

Scientific theories are consistent explanations about how the world works. They have been shown to be plausible not only from a large amount of independent confirmatory evidence but also because rigorous attempts at falsification have failed. Other desirable features include parsimony, scalability, explanatory, and predictive power. Scientific theories differ from models and laws in the amount of evidence available and/or the degree to which they explain nature. Learning curve theory is a scientific theory with direct applicability to simulation education researchers. In this article, the authors use the example of learning curve theory to illustrate the key features of scientific theories and how they provide a meaningful foundation for simulation-based education research programs.

Supplemental Digital Content is available in the text.Collecting and analyzing large amounts of process data for the purposes of education can be considered a big data/learning analytics (BD/LA) approach to improving learning. However, in the education of health care professionals, the application of BD/LA is limited to date. The authors discuss the potential advantages of the BD/LA approach for the process of learning via cognitive simulations. Using the lens of a cognitive model of radiograph interpretation with four phases (orientation, searching/scanning, feature detection, and decision making), they reanalyzed process data from a cognitive simulation of pediatric ankle radiography where 46 practitioners from three expertise levels classified 234 cases online. To illustrate the big data component, they highlight the data available in a digital environment (time-stamped, click-level process data). Learning analytics were illustrated using algorithmic computer-enabled approaches to process-level feedback.For each phase, the authors were able to identify examples of potentially useful BD/LA measures. For orientation, the trackable behavior of re-reviewing the clinical history was associated with increased diagnostic accuracy. For searching/scanning, evidence of skipping views was associated with an increased false-negative rate. For feature detection, heat maps overlaid on the radiograph can provide a metacognitive visualization of common novice errors. For decision making, the measured influence of sequence effects can reflect susceptibility to bias, whereas computer-generated path maps can provide insights into learners’ diagnostic strategies.In conclusion, the augmented collection and dynamic analysis of learning process data within a cognitive simulation can improve feedback and prompt more precise reflection on a novice clinician’s skill development.

To determine the sensitivity of parental suspicion of concussion relative to paediatric emergency physicians in children who presented to an emergency department (ED) with a head injury. A secondary objective was to examine the variables associated with parental suspicion of concussion concordant with that of a physician.

I congratulate CMAJ and Boutis and colleagues for a brilliant research paper. (1) Intention-to-treat analysis is a comparison of the treatment groups that includes all patients as originally allocated after [...]

AbstractProspective research studies often advance clinical practice in the emergency department (ED), but they can be costly and difficult to perform. In this report, we describe the implementation of a volunteer university student research assistant program that provides students exposure to medicine and clinical research while simultaneously increasing the capacity of an ED’s research program. This type of program provides 15 hours per day of research assistant coverage for patient screening and enrolment for minimal risk research studies, and screening for higher risk studies. The latter is true without the added burden or costs of co-administering university course credit or pay for service, which are common features of most of these types of programs currently in operation. We have shown that our volunteer-based program is effective for an ED’s research success as well as for its student participants. For other EDs interested in adopting similar programs, we provide the details on how to get such a program started and highlight the structure and non-monetary incentives that facilitate a program’s ongoing success.

Supplemental Digital Content is available in the text.Learning curves, which graphically show the relationship between learning effort and achievement, are common in published education research but are not often used in day-to-day educational activities. The purpose of this article is to describe the generation and analysis of learning curves and their applicability to health professions education. The authors argue that the time is right for a closer look at using learning curves—given their desirable properties—to inform both self-directed instruction by individuals and education management by instructors.A typical learning curve is made up of a measure of learning (y-axis), a measure of effort (x-axis), and a mathematical linking function. At the individual level, learning curves make manifest a single person’s progress towards competence including his/her rate of learning, the inflection point where learning becomes more effortful, and the remaining distance to mastery attainment. At the group level, overlaid learning curves show the full variation of a group of learners’ paths through a given learning domain. Specifically, they make overt the difference between time-based and competency-based approaches to instruction. Additionally, instructors can use learning curve information to more accurately target educational resources to those who most require them.The learning curve approach requires a fine-grained collection of data that will not be possible in all educational settings; however, the increased use of an assessment paradigm that explicitly includes effort and its link to individual achievement could result in increased learner engagement and more effective instructional design.

Supplemental Digital Content is available in the text.

Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs).

Randomized trials have shown that removable immobilization devices are at least as good as circumferential casts for the management of common specific types of pediatric wrist and ankle fractures. Our main objective was to determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures andor nondisplaced distal fibular Salter-Harris I fractures. We also examined follow-up referral patterns for these injuries.

To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined.

The primary objective of this study was to determine if Gartland type I supracondylar humerus (SCH) fractures undergo significant displacement resulting in a change in management when treated with a long-arm splint. Secondary objectives included measured changes at follow-up in displacement andor angulation.

The unlikely event of long-term complications in some pediatric fractures, such as midclavicular fractures, has allowed for management of these injuries with interventions that support the injured extremity rather than immobilize it while healing occurs. However, there is currently a growing body of evidence that advocates for this approach for some of the most frequently encountered pediatric fractures also at very low risk of future problems but, in contrast, have conventionally been managed with orthopedic consultation and rigid casting for several weeks. Therefore, this article will review the evidence that recommends that management of some of the most common upper and lower pediatric extremity fractures be treated with minimal interventions, such as removable splints and follow-up with a primary care provider.

ABSTRACTBackground:Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.Objectives:The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.Methods:This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (=15° of angulation in the sagittal plane and =0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.Results:Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated =20° within the follow-up period. Two (1.6%) fractures that were initially angulated =15° progressed to 30°–35°, but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.Conclusions:Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.

Although local anesthetic techniques (hematoma blocks, nerve blocks, intravenous regional anesthesia) for forearm fracture reduction are well described and commonly used in adults, it is unclear how often these techniques are used in children.

IntroductionRest until symptom-free, followed by a progressive stepwise return to activities, is often prescribed in the management of paediatric concussions. Recent evidence suggests prolonged rest may hinder recovery, and early resumption of physical activity may be associated with more rapid recovery postconcussion. The primary objective is to determine whether the early reintroduction of non-contact physical activity beginning 72 hours postinjury reduces postconcussive symptoms at 2 weeks in children following an acute concussion as compared with a rest until asymptomatic protocol.Methods and analysisThis study is a randomised clinical trial across three Canadian academic paediatric emergency departments. A total of 350 participants, aged 10–17.99 years, who present within 48 hours of an acute concussion, will be recruited and randomly assigned to either the study intervention protocol (resumption of physical activity 72 hours postconcussion even if experiencing symptoms) or physical rest until fully asymptomatic. Participants will document their daily physical and cognitive activities. Follow-up questionnaires will be completed at 1, 2 and 4 weeks postinjury. Compliance with the intervention will be measured using an accelerometer (24 hours/day for 14 days). Symptoms will be measured using the validated Health and Behaviour Inventory. A linear multivariable model, adjusting for site and prognostically important covariates, will be tested to determine differences between groups. The proposed protocol adheres to the RCT-CONSORT guidelines.DiscussionThis trial will determine if early resumption of non-contact physical activity following concussion reduces the burden of concussion and will provide healthcare professionals with the evidence by which to recommend the best timing of reintroducing physical activities.Trial registration numberTrial identifier (Clinicaltrials.gov) NCT02893969.

IMPORTANCE: The natural progression of symptom change and recovery remains poorly defined in children after concussion. OBJECTIVES: To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery. DESIGN, SETTING, AND PARTICIPANTS: Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018. EXPOSURES: Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point. MAIN OUTCOMES AND MEASURES: The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed. RESULTS: A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, −5.3; 95% CI, −5.5 to −5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, −9.0; 95% CI, −9.6 to −8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, −28.6; 95% CI, −30.8 to −26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12. CONCLUSIONS AND RELEVANCE: Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.

Trial RegistrationClinicaltrials.gov Indentifier: NCT01873287.ObjectiveTo investigate if early physical activity (7-days post-injury) was associated with lower risk of persistent post-concussive symptoms (PPCS) compared to guideline-recommended conservative rest.DesignProspective, multicenter, cohort study.SettingNine tertiary Canadian Paediatric EDs.Participants2413 children (61% male) aged 5-18 years with acute concussion (<48 hours) with inclusion/exclusion criteria per Predicting Persistent Post-concussive Problems in Paediatrics (5P) study.Assessment of risk factorsParticipation in physical activities, post-concussive symptoms, and concussion modifiers were assessed using standardised questionnaires at baseline, 7- and 28-days post-injury.Outcome measuresPPCS (primary outcome) was defined as ≥3 new or worsening symptoms on Post-Concussion Symptom Inventory at 28-days post-enrolment. The relationship between early physical activity and PPCS was examined using regression, 1:1 propensity-matched, and inverse probability of treatment weighting (IPTW) analyses.ResultsPPCS occurred in 678/2413 (30.1%) participants. Most children (n=1677, 70%) participated in physical activity at one-week of which only n=528 (31%) were symptom-free. Early physical activity was associated with reduced likelihood of PPCS [regression: OR=0.42, (95% CI: 0.35–0.51)]. Early activity remained associated with reduced PPCS risk when matched 1:1 for propensity score [n=1290, OR=0.56, (95% CI: 0.44–0.71)], and using IPTW [n=2235, OR=0.62, (95% CI: 0.51–0.76)]. Sensitivity analyses (replacement of baseline symptoms with one-week symptoms) maintained significant associations [regression: OR=0.42, (95% CI: 0.35–0.51); propensity matching: OR=0.75, (95% CI: 0.60–0.94); and IPTW: OR=0.69, (95% CI: 0.57–0.85)].ConclusionsPhysical activity within 7-days post-injury was associated with lower risk for PPCS in youth recovering from acute concussion. RCTs are urgently needed to confirm these findings and to determine the optimal timing of the initiation of physical activity.Competing interestsNo competing interests to disclose. This study was supported by Canadian Institutes of Health Research (CIHR) Operating Grant MOP:#126197; CIHR-Ontario Neurotrauma Foundation Mild Traumatic Brain Injury Team Grant TM1:#127047; and CIHR planning grant MRP: #119829.None.

IMPORTANCE: Persistent postconcussion symptoms (PPCS) pose long-term challenges and can negatively affect patients’ health-related quality of life (HRQoL). To date, no large comprehensive study has addressed the association between PPCS and HRQoL. OBJECTIVES: To determine the association between HRQoL and PPCS at 4 weeks after concussion and assess the degree of impairment of HRQoL in the subsequent 12 weeks. DESIGN, SETTING, AND PARTICIPANTS: In a prospective, multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics [5P]) from August 14, 2013, to September 30, 2014, children aged 5 to 18 years who presented to the emergency department within 48 hours after head injury and were considered to have an acute concussion were enrolled across 9 pediatric emergency departments within the Pediatric Emergency Research Canada Network. Persistent postconcussion symptoms were defined as 3 or more persistent symptoms on the validated Post-Concussion Symptom Inventory at 4 weeks. Linear mixed effects random coefficients models evaluated the association between PPCS and HRQoL, adjusting for potential confounders including age, sex, prior concussions, migraine, anxiety, learning disability, depression, and sleep disorder. MAIN OUTCOMES AND MEASURES: The primary outcome was HRQoL assessed with the validated Pediatric Quality of Life Inventory version 4.0 (PedsQL-4.0) at 4, 8, and 12 weeks after head injury. RESULTS: Of 2006 children enrolled (median age, 11.8 years [interquartile range, 8.9-14.6 years]; 1241 boys and 765 girls), 1667 (83.1%) completed the PedsQL-4.0 at all 3 time points. Of these 1667 children, the 510 with PPCS (30.6%) had lower total PedsQL-4.0 scores (mean, 70.0) than did those without PPCS (mean, 80.3; mean difference, –10.3; 95% CI, −9.4 to −11.2). Patients with PPCS also had significantly lower physical, emotional, social, and school PedsQL-4.0 subscores at 4, 8, and 12 weeks. Patients with PPCS had lower HRQoL than published healthy norms at 4 weeks (mean difference, 13.89; 95% CI, 11.55-16.23), 8 weeks (mean difference, 11.63; 95% CI, 9.34-13.93), and 12 weeks (mean difference, 9.38; 95% CI, 7.01-11.75; P &lt; .001). Patients who recovered from concussion also had lower HRQoL than norms at 4 weeks (mean difference, 3.56; 95% CI, 1.28-5.85) and 8 weeks (mean difference, 2.75; 95% CI, 0.48-5.02; P &lt; .05). School functioning PedsQL-4.0 subscores were significantly lower for all children regardless of PPCS status at all time points. CONCLUSIONS AND RELEVANCE: Children with PPCS have lower HRQoL compared with those who have recovered from concussion, yet deficits in HRQoL are pervasive across all domains and may persist for months even in children whose symptoms have resolved. Future interventional research should target the effect of concussion on HRQoL.

IMPORTANCE: Lateral ankle injuries without radiographic evidence of a fracture are a common pediatric injury. These children are often presumed to have a Salter-Harris type I fracture of the distal fibula (SH1DF) and managed with immobilization and orthopedic follow-up. However, previous small studies suggest that these injuries may represent ankle sprains rather than growth plate fractures. OBJECTIVES: To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted between September 2012 and August 2014 at 2 tertiary care pediatric emergency departments. We screened 271 skeletally immature children aged 5 to 12 years with a clinically suspected SH1DF; 170 were eligible and 140 consented to participate. INTERVENTIONS: Children underwent MRI of both ankles within 1 week of injury. Children were managed with a removable brace and allowed to return to activities as tolerated. MAIN OUTCOMES AND MEASURES: The proportion with MRI-confirmed SH1DF. A secondary outcome included the Activity Scale for Kids score at 1 month. RESULTS: Of the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%) demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were intermediate to high-grade injuries, 38 of which were associated with radiographically occult fibular avulsion fractures. At 1 month, the mean (SD) Activity Scale for Kids score of children with MRI-detected fibular fractures (82.0% [17.2%]) was not significantly different from those without fractures (85.8% [12.5%]) (mean difference, −3.8%; 95% CI, −1.7% to 9.2%). CONCLUSIONS AND RELEVANCE: Salter-Harris I fractures of the distal fibula are rare in children with radiograph fracture–negative lateral ankle injuries. These children most commonly have ligament injuries (sprains), sometimes associated with radiographically occult avulsion fractures. Children with fractures detectable only by MRI had a comparable recovery with those with sprains when treated with a removable ankle brace and self-regulated return to activities. This work has the potential to simplify the care of these common injuries, safely minimizing the inconveniences and costs of overtreatment.