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The United States Medical Licensing Examination (USMLE) Step 1 examination will transition from graded to pass/fail scoring starting no earlier than January 2022. Orthopedic surgery residency programs will need to adapt to these changes. The goal of this study was to investigate the perceptions of orthopedic surgery residency program directors on the change of Step 1 from a graded to a pass/fail examination. We also investigated how the change would affect the other factors that are typically considered in the selection of orthopedic surgery residents. A survey was distributed to 161 directors of allopathic orthopedic surgery programs. Contact information was obtained from a national database. Of those contacted, 75 (46.6%) program directors responded. Most (85.3%) did not support the pass/fail change. Most believe that greater importance will be placed on the Step 2 Clinical Knowledge examination (96.0%), audition elective with their department (84.0%), personal knowledge of the applicant (78.7%), grades (74.7%), letters of recommendation from recognizable orthopedic surgeons (74.7%), and Alpha Omega Alpha status (69.3%). Most also believe that this change will advantage allopathic students who attend highly regarded schools (58.7%). Most of the program directors support a graded preclinical curriculum (69.3%) and caps on the number of orthopedic surgery residency applications (70.7%). Although most orthopedic surgery program directors disagree with the change to a pass/fail Step 1 examination, residency programs will need to reevaluate how they screen applicants for an interview once the scored Step 1 is no longer available. With this change, other factors, such as Step 2 score, audition rotations, and grades in clerkships, will be emphasized more heavily. [ Orthopedics . 2022;45(1):e30-e34.].

Background: United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process., Methods: A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database., Results: We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit., Conclusion: Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Competing Interests: The authors have no conflicts of interest to disclose.

The purpose of this case series is to report the outcomes of ossicle excision and tubercleplasty for unresolved Osgood-Schlatter disease that has failed conservative treatment in six adolescent athletes. A retrospective chart review was completed, and data collected include age at onset of symptoms, age at surgery, sex, laterality, mechanism of injury, conservative treatment regimen, radiographic findings, sports played, time to return to sport, length of follow-up, and Lysholm score. Surgery involved an open ossicle excision, tubercleplasty, and repair of the patellar tendon to bone using a suture anchor. Postoperatively, patients were allowed to fully weight-bear in an extension knee brace for 4 weeks and then allowed to gradually resume activity. Four males and 2 females were studied. The right knee was involved in 3 cases and the left knee in 3. The average age at onset of symptoms was 15.8 (range 12-18) and at surgery was 17.3 (range 17-18). Radiographic findings included a large bump in 4 cases, an ossicle in 2, and free fragments at the tendon insertion in 3. Sports played included basketball, football, running, and dancing. All patients returned to sports at an average of 21 weeks and 6 days postsurgery (range 8-56). The average length of follow-up was 14.2 weeks (range 5-27). The average Lysholm score postsurgery was 97.2 (range 94-100). Surgical treatment of unresolved Osgood-Schlatter disease was successful in all patients. No patients reported any postoperative complications or additional surgery. For skeletally mature and symptomatic patients, we recommend removal of the ossicle and adjacent bursae, smoothing the bump, and repairing the patellar tendon to bone., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Frederick Mun and William L. Hennrikus.)

Purpose: Supracondylar humerus (SCH) fractures are the most common elbow fracture in children; however, they rarely occur as open injuries. Open fractures are associated with higher rates of infection, neurovascular injury, compartment syndrome, and nonunion. The purpose of this study was to evaluate the treatment and outcomes of open SCH fractures in children., Methods: Between 2008 and 2015, four children (1%) had open injuries among 420 treated for SCH fractures at a single center. The mean patient age was six years (range, four to eight years). Two patients had Gustilo-Anderson grade 1 open fractures and two had grade 2 fractures. Tetanus immunization was up-to-date in all. First dose of intravenous antibiotics was given on average 3hr 7min after onset of injury (range, 1hr 38min to 8hr 15min). Time from injury to irrigation and debridement (I&D) and closed reduction and percutaneous pinning (CRPP) was on average 8hr 16min (range, 4hr 19min to 13hr 15min). All patients received 24-hour intravenous antibiotics. Pins were removed at four weeks and bony union occurred by six weeks., Results: After an average follow-up period of 12 months (range, 6 to 22 months), there were no infections, neurovascular deficits, compartment syndromes, cubitus varus deformities, or range of motion losses. All outcomes were excellent according to the Flynn criteria. Due to the unstable nature of open SCH fractures, a medial pin was used in all four cases. No loss of reduction or ulnar nerve injury occurred., Conclusion:  Open injuries occur in approximately 1% of all SCH fractures in children. The authors recommend urgent intravenous antibiotics, I&D, and CRPP involving a medial pin to treat open SCH fractures. Excellent outcomes based on the Flynn criteria were obtained in four cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Pan et al.)

Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Tommy Pan et al.)

How medical inter-professional (IP) education should be introduced to students is still a matter of research. We evaluated IP student attitudes before and after a busy "hands-on" clinical experience.During 3 separate trips, first/second year medical and physician assistant students and third/fourth year nursing students traveled to Central America to work together for 1 week in an underserved clinical setting. Student opinions on inter-professional education were obtained before and after Brigade-1 using the Readiness for Inter-professional Learning Scale validated questionnaire. From these results, a modified version of the survey was developed that included quantitative and qualitative responses. For brigades-2 and -3, students received this modified version of the survey pre and post brigade. Quantitative data was analyzed via paired student t test, and qualitative data was analyzed to identify emerging themes using constant comparative methodology by three separate investigators.No significant quantitative differences between IP student groups were observed in their evaluation of the importance of inter-professional education either before or after the brigades. Qualitative data noted pre-brigade expectations of positive IP, experiential and patient-centered cultural learning. Pre- and post-brigade student perspectives maintained a strong belief that high functioning IP care benefited the patient. Post-brigade perspectives revealed a shift in attitude from purely positive expectations to more practical aspects of teamwork, respect, and interpersonal relationships.Students believe that patient care benefits from IP collaboration. After a busy clinical experience requiring collaboration, students realized that functional teams require appropriate skills, roles, and respectful interpersonal relationships.

The incidence of iliopsoas tendonitis (IPT) has not previously reported following hip arthroscopy for femoroacetabular impingement with or without labral tears. (i) What is the incidence of IPT following hip arthroscopy; (ii) are there any demographic risk factors and (iii) are there any operative techniques that are risk for IPT? Retrospective study. Hip arthroscopy patients from 2005 to 2012 were included. Patients were diagnosed via physical examination findings and were excluded if they had pre-operative IPT. Records were reviewed for demographics, operative reports and operative procedures. All patients received either labral debridement, labral repair, osteoplasty or a combination of those procedures. A standardized rehabilitation protocol was used. Of 252 patients, 60 (24%) had IPT. Twenty-eight (47%) had symptom resolution with activity modification, physical therapy and NSAIDs. Thirty-two (53%) required corticosteroid injection at a mean of 25 weeks after surgery. Seven (12%) required revision arthroscopy and iliopsoas release to resolve the symptoms. There were no patient-specific risk factors, differences based on surgical technique, and number of portals did not matter. Patients should minimize exercises that activate the iliopsoas after hip arthroscopy. The cause of IPT could be related to unaddressed abnormal mechanics, tendon scarring or improper physical therapy. Further studies are needed to investigate the reasons for this, as well as specific techniques to lower its incidence. The incidence of IPT after hip arthroscopy has an incidence of 24%. Additionally, we provide readers with a rehabilitation protocol to minimize this complication., What Is Known About the Subject: This subject has not previously been described., What This Study Adds to Existing Knowledge: We are the first to report IPT after hip arthroscopy.

A long arm cast with the elbow extended is a useful but often forgotten technique to manage some pediatric fractures. Specifically, proximal forearm fractures of both the radius and ulna, olecranon fractures, flexion-type supracondylar fractures and type II Monteggia fractures are well managed in this manner. Although some of these fractures are seen infrequently, timely diagnosis and treatment are essential to prevent complications. In this article, we present a review of the evaluation and management of these fractures in children, and a description of the technique used to apply a long arm cast in extension.

Purpose: The purpose of this study is to report the spectrum of injuries sustained by competitive paediatric motocross athletes at a level I trauma centre., Patients and Methods: A retrospective study of paediatric competitive motocross injuries treated at a level I trauma centre between 2004 and 2014 was performed. Athletes were included if aged less than 18 years and injured while practising or competing on a competitive motocross track. Medical records were reviewed for age, gender, race, location of accident, use of safety equipment, mechanism of injury, injury type and severity, Glasgow Coma Score at hospital presentation and Injury Severity Score (ISS)., Results: In total, 35 athletes were studied. The average age was 14 years. One athlete died. Thirty athletes were injured during competition; five were injured during practice. Twenty-four athletes (69%) suffered an orthopaedic injury with a total of 32 fractures and two dislocations. Two fractures were open (6.3%). Lower extremity fractures were twice as common as upper extremity fractures. Surgery was more common for lower extremity fractures-83% versus 30%. The most common fractures were femoral shaft (18.8%), fibula (12.5%), clavicle (12.5%), tibial shaft (9.4%) and forearm (9.4%)., Conclusions: Competitive paediatric motocross athletes suffer serious, potentially life-threatening injuries despite the required use of protective safety equipment. Femoral shaft, fibula and clavicle were found to be the most commonly fractured bones. Further prospective research into track regulations, protective equipment and course design may reduce the trauma burden in this athlete population.

Background: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children., Questions/purposes: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved?, Methods: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old., Results: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type., Conclusions: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children., Level of Evidence: Level IV, therapeutic study.

Purpose: Fractures are the second most common presentation of child abuse following soft-tissue bruising and burns. It is often difficult to determine potential abuse in a child presenting with a non-rib fracture(s) and without soft-tissue injuries., Methods: One hundred and fifteen consecutive patients aged ≤2 years who presented with a fracture between January 2010 and June 2012 to our emergency department (ED) or pediatric fracture clinic were retrospectively analyzed. Statistical analyses were carried out for non-accidental fractures based on age (<1 year vs 1-2 years), location of presentation (ED vs pediatric fracture clinic), type of long bone fracture, number of fractures, and patient demographics., Results: Fractures in 19 of 115 (17 %) patients were reported as non-accidental trauma (NAT). Eighty (70 %) of the 115 patients first reported to the ED. Thirty-two percent of fractures in children aged <1 year and 5 % of fractures in children aged 1-2 years were reported as NAT (p < 0.001). Sixteen of 19 (84 %) patients reported for abuse had multiple fractures; 15 of these patients were aged <1 year. Eight of 11 (73 %) reported femoral fractures were transverse fractures. Corner fractures (12) only occurred in children aged <1 year and never occurred in isolation; all of them were reported as NAT. Four of 60 patients (7 %) with commercial insurance and 15 of 55 patients (28 %) with Medicaid were reported as NAT., Conclusions: Age less than 1 year, multiple fractures, corner fractures, transverse fractures, and covered by Medicaid were the most common factors associated with reporting of NAT.

Background. Septic arthritis of the glenohumeral joint in the pediatric population (<18 yo) is not commonly described in the literature. There is a corresponding paucity of information regarding its presentation and treatment. Methods. An IRB approved review of patients treated with irrigation and debridement by the Orthopaedic Department was completed. This retrospective study includes four patients, presenting from 2005 to 2015, with septic arthritis of the shoulder. Results. The mean age (M age) at presentation was 5 years, with a range of 1 month to 15 years. Patients presented on average after 7 days with pain and a mean temperature of 39°C, erythrocyte sedimentation rate of 66 mm/hr, a C-reactive protein level of 11.17 g/dL, and a white blood cell count of 20.2 × 10(3)/mcL. Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa were cultured from the wounds. All cases were treated operatively with irrigation and debridement and with antimicrobial therapy. Patients received antibiotics for an average of 6 weeks. Conclusion. Septic arthritis of the shoulder occurs in all pediatric ages. Successful treatment of septic arthritis of the shoulder was accomplished in four cases without division of the biceps sheath, with an average follow-up of 8 months.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) has been described as a risk factor for postsurgical infection. The purpose of this study is to determine the prevalence of MRSA in pediatric orthopaedic patients and whether being a MRSA carrier is a predictor of postoperative infection. Six hundred and ninety-nine consecutive pediatric patients who underwent MRSA nasal screening prior to surgery were studied. Postoperative cultures, total surgical site infections (SSIs), and epidemiological and surgical prophylaxis data were reviewed. Forty-four of 699 patients (6.29%) screened positive for MRSA. Nine of the 44 patients (20.5%) that screened positive for MRSA had a subsequent SSI compared to 10 of the 655 patients (1.52%) that screened negative (p < 0.05). All 9 patients with a SSI had myelomeningocele. The prevalence of MRSA was 6.30% and was predictive of postoperative infection. Children with myelomeningocele were at the highest risk for having a positive MRSA screening and developing SSI.

Chronic exertional compartment syndrome (CECS) is a relatively rare condition that affects young adult athletes and often causes them to present to the emergency department. If left untreated, those who continue to compete at high levels may experience debilitating leg pain. Physicians may have difficulty differentiating CECS from other syndromes of the lower leg such as medial tibial stress syndrome, stress fractures, and popliteal artery entrapment. The gold standard for diagnosing CECS is intramuscular compartment pressure monitoring before and/or after 10 minutes of exercise. Some patients may choose to stop participation in sports in order to relieve their pain, which otherwise does not respond well to nonoperative treatments. In patients who wish to continue to participate in sports and live an active life, fasciotomy provides relief in 80% or more. The typical athlete can return to training in about 8 weeks. This is a case of a high school soccer player who stopped competing due to chronic exertional compartment syndrome. She had a fascial hernia, resting intramuscular pressure of 30 mmHg, and postexercise intramuscular pressure of 99 mmHg. Following fasciotomy she experienced considerable life improvement and is once again training and playing soccer without symptoms.

Purpose: Patients with lipomyelomeningocele (LMMC) represent a unique population within the spectrum of spinal dysraphism. The natural history of LMMC remains poorly defined. The description and prevalence of the presenting orthopaedic clinical signs and symptoms for LMMC have been infrequent and often documented only in general terms. The goal of this study is to define the patterns and prevalence of presenting clinical musculoskeletal signs and symptoms in LMMC patients., Methods: This study was a retrospective review of charts of all patients identified as having LMMC in our spina bifida clinic. Patient charts with incomplete data or diagnoses other than LMMC were excluded from the analysis. Data collected included age at initial tethered cord release (TCR); repeat TCR; limb length discrepancy; foot deformities; asymmetry of motor and sensory deficits; presence of scoliosis; orthotic needs; assistive devices; functional status., Results: We identified 32 patients with LMMC (21 female and 11 male patients). The majority of patients had their primary TCR by ≤1 year of age (59 %), with 22 and 19 % having primary TCR at ages 1-15 and >15 years, respectively. Fifteen patients had at least one repeat TCR, with ten of these having more than one repeat TCR. A significant relationship was noted between low back/radicular pain and repeat TCR (p < 0.001). Ten patients (31%) had a limb length discrepancy of >2.5 cm, and 53 % of patients had asymmetric involvement. Nine patients (28 %) had scoliosis of whom only one required operative treatment. Fifteen patients had foot deformities. Thirteen patients (41 %) had two or more orthopaedic procedures in addition to other neurologic or urologic procedures., Conclusion: The presenting musculoskeletal clinical signs and symptoms in patients with LMMC are uniquely different in terms of both pattern and frequency compared to myelomeningocele and other forms of spinal dysraphism. We noted a high prevalence of asymmetrical involvement, a high operative burden, and a high rate of repeat symptomatic tethered cord syndrome requiring TCR. As previously noted by others, TCR in LMMC does not prevent long-term functional deterioration. These findings may be important to our colleagues providing counsel to their patients with LMMC and to their families.