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Resumen Introduccion Las fracturas de condilo humeral lateral (FCHL) representan del 12 al 17% de las fracturas de codo pediatrico. La asociacion de esta fractura con luxacion de codo es poco comun, siendo escasa la bibliografia y generalmente limitada a reportes de casos. Nuestro objetivo fue revisar sistematicamente la literatura sobre las fracturas del condilo lateral del humero asociadas a luxacion de codo en ninos. Metodos Se realizo una revision sistematica mediante una busqueda exhaustiva en las bases de datos PubMed y Embase de literatura revisada por pares entre 1960 y 2020. Dos revisores filtraron los resultados y buscaron articulos en ingles o espanol que reportan pacientes esqueleticamente inmaduros con fracturas del condilo lateral del humero asociadas a luxacion de codo. Los resultados analizados incluyeron caracteristicas del paciente y de la lesion, estrategias de tratamiento, complicaciones y resultados finales. Resultados La busqueda inicial arrojo un total de 851 estudios. Despues de la revision, se incluyeron 16 estudios, con 67 pacientes disponibles para revision. Las edades reportadas al momento de la lesion variaron entre 2 y 12 anos. La lesion se presento mas comunmente en varones con fracturas tipo Milch II, Jakob tipo 3. La direccion de la luxacion fue posteromedial en la mayoria de los casos. La reduccion abierta por abordaje lateral y la colocacion de clavijas Kirschner fue el tratamiento mas comunmente realizado. El seguimiento reportado se presento en un rango 3 a 156 meses. Catorce estudios informaron complicaciones en un tercio de los pacientes, que incluyen: limitacion del rango de movimiento, cubito varo, inestabilidad, prominencia del implante, retraso de la consolidacion, seudoartrosis, consolidacion viciosa, osificacion heterotopica, lesion neurologica y fallo del implante. Trece estudios informaron resultados clinicos, que se calificaron como regulares o pobres en 2 de cada 10 pacientes. Conclusiones La evidencia actual es nivel iv y sugiere que la tasa de complicaciones despues del manejo quirurgico de las fracturas de condilo lateral es elevada en el contexto de una luxacion de codo, lo que se asocia ademas a un alto porcentaje de resultados suboptimos. Las complicaciones mas frecuentes en esta serie fueron la rigidez articular y el cubito varo.

Purpose Distal radius fractures (DRFs) are common pediatric injuries typically treated with closed reduction and casting. A substantial number of these fractures fail nonsurgical management, occasionally requiring surgical intervention. Risk factors associated with an unsuccessful initial closed reduction (UIR) attempt or loss of reduction (LOR) after a successful closed reduction remain poorly characterized. Methods This was a retrospective investigation of pediatric patients with displaced DRFs treated by closed reduction and casting at a single children’s hospital from 2013 to 2017. Patient factors (age, sex, and body mass index) and radiographic measurements (fracture type, fracture displacement, associated ulna fracture, and cast index) were evaluated to determine risk factors for UIR and LOR. Results We identified 159 children (118 boys, mean age, 11 ± 3 years) with DRFs who underwent closed reduction and casting. An initial acceptable reduction was achieved in 81% of patients, and LOR occurred in 21.7%. Higher initial fracture translation in the sagittal or coronal plane and higher initial angulation in the coronal plane were associated with higher fluoroscopy times. Higher initial translation in the sagittal plane was independently associated with UIR. After closed reduction, residual translation in the sagittal plane and cast index were independent predictors for LOR. Fractures that were completely displaced in the sagittal plane were 6.2 times less likely to undergo an acceptable initial reduction, and fractures with any residual postreduction translation in the sagittal plane were 4.7 times more likely to demonstrate LOR. Conclusions The most important factors predicting failure of nonsurgical management of pediatric DRFs are translation in the sagittal plane and cast index greater than 0.80. To optimize patient outcomes, these variables should be recognized by the treating provider and emphasized during simulation training of orthopedic and plastic surgery residents. Type of study/level of evidence Prognostic III.

Background In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. Methods Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. Results A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1–17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60–100%). Mean follow-up was 5.17 years (2–12 years). Conclusion This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Distal femur physeal fractures are known to have a high incidence of complications. Our previous reported experience (pre-2007) showed a 40% complication risk, which prompted changes in our approach. The purpose of this study was to evaluate and compare the complication rate and outcome after implementation of these changes. This is a retrospective study of children with distal femur physeal fractures treated at a level 1 pediatric trauma center between 2007 and 2016. Patient demographics, fracture patterns, treatment and outcomes including complications and its risk factors were recorded and analyzed. We compared current results with our previously reported multicenter cohort (n = 73). Patients were male in majority (57/70) with a mean age of 13 ± 4 years. Fractures were most commonly Salter-Harris Type 2 (49/70) and displaced (59/70) on presentation, although neither characteristic was associated with complications. Most patients (63/70) were treated surgically, and the overall complication incidence was 36% (25/70), including growth arrest in 20 patients. The pre-2007 cohort was statistically significantly younger (P < 0.001) and was more commonly treated nonoperatively (P < 0.001). However, there was no statistically significant difference in complication incidence between studies (36% versus 40%, respectively, P = 0.751). Despite a lower threshold for surgery for distal femur physeal fractures in the past decade, the complication rate is still high and unchanged at 40%, and presenting patients are older. There were no new prognostic factors that showed statistically significant association with subsequent complications; however, patients with high-energy injury mechanisms and greater fracture displacements did have higher complication rates. These results demonstrate the inherent high complication risk for these injuries. Level of Evidence: III.

Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures.This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P0.01 considered significant.One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient.There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center.This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Case Here, we present the case of a pediatric polytrauma patient found to have lower extremity intra-arterial fat embolism causing ischemic necrosis and ultimately necessitating below-the-knee amputation. Conclusion Fat embolism, a common complication of long bone fractures in adults, can be associated with significant morbidity. Although rare, it should be considered among the possible etiologies for a pulseless limb after trauma. Early fracture stabilization may prevent fat embolism and fat embolism syndrome; however, there is no known definitive treatment, and management is supportive.

The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management).A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded.In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group.There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures.Level III.

BACKGROUND Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. METHODS We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. RESULTS We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

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

Background The treatment of acute pediatric Monteggia injuries involving a complete fracture of the ulna remains controversial. The purpose of this study is to compare the outcomes of immediate operative fixation to a trial of closed reduction and casting of acute pediatric Monteggia fractures involving complete ulna fractures. Methods We performed a retrospective analysis of 73 patients with Monteggia injuries with complete ulna fractures presenting to 2 pediatric trauma centers from 2008 to 2018. Patients were divided in 2 groups based on the treatment received: patients in group 1 (n=37, 51%) received surgical treatment; patients in group 2 (n=36, 49%) received a trial of closed reduction and casting. The mean follow-up of 15.2 weeks (range, 4.1 to 159 wk). The incidence of radiocapitellar joint redislocation, need for further intervention, complications, and recovery of range of motion was compared between the groups. Results There were no significant differences between groups 1 and 2 with regards to age (6 vs. 5.8 y, P=0.69), sex (54% vs. 47% female, P=0.64), or the mean maximal ulnar angulation (23 vs. 19 degrees, P=0.94). There was a higher proportion of proximal ulna fractures in group 1 versus 2 (62% vs. 33%, respectively, P=0.02). Bado type III and IV fractures were associated with operative management [odds ratio=22 (95% confidence interval: 1.68-288.7) and 14.9 (95% confidence interval: 2.09-106), respectively]. In group 2, 5 patients (13.9%) sustained a loss of radiocapitellar joint reduction following closed reduction and casting and ultimately received operative treatment. At final follow-up, there were no cases of recurrent radiocapitellar dislocation in either group, all patients achieved fracture union and regained full elbow range of motion. Conclusions Even in the presence of a complete ulna fracture, a trial of nonoperative management of acute pediatric Monteggia fractures with closed reduction and casting can result in comparable outcomes to those obtained with immediate surgical management. The nonoperative management of Monteggia fractures requires close clinical follow-up to ensure no loss of reduction. Level of evidence Level IV-therapeutic studies, case series.

CASE We describe a case of a 9-year-old boy who presented with a left calf mass consistent with alveolar rhabdomyosarcoma involving the Achilles tendon. The patient underwent radical resection of the Achilles tendon and Achilles tendon allograft reconstruction. At 2.5-year follow-up, the child had full ankle range of motion and strength and no signs of disease. CONCLUSIONS Radical resection of Achilles tendon in the setting of malignancy and reconstruction with allograft is a rare procedure that has not been previously described in the pediatric population. Orthopaedic oncologists can consider this option for the rare malignancies involving the Achilles tendon.

BACKGROUND Operative treatment of medial epicondyle fractures can be performed in either a supine or prone position. In the supine position, fracture visualization is sometimes difficult due to the posterior position of the medial epicondyle. However, the prone position requires extensive patient repositioning but may improve visualization. The purpose of this study was to compare the results and complications between the supine and prone position when treating medial epicondyle fractures. METHODS In a retrospective chart review, patients below 18 who underwent open reduction and internal fixation of an acute medial epicondyle fracture from January 2011 to August 2019 were identified. Patients with

Case A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques. Conclusions In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component.

A triplane fracture is an example of a transitional fracture of adolescence that occurs because the distal tibial physis closes in a predictably asymmetric way from central to medial and then lateral. The triplane fracture is so named because the fracture lines propagate in 3 planes (axial, sagittal, and coronal) and thus appear on radiographs as a Salter-Harris III pattern on anteroposterior images and Salter-Harris II or IV on lateral images. The fracture occurs via a twisting mechanism (usually supination and external rotation) through the relatively weak open portion of the physis (axial) and propagates out the metaphysis (coronal) and/or epiphysis (sagittal) at the transition to the relatively stronger closed portion of the physis. Because the distal tibial physis closes over approximately an 18-month period in female patients from 12 to 14 years old and male patients from 13 to 15 years old, this is the age range in which triplane fractures occur. Triplane fractures account for approximately 5% to 10% of pediatric ankle fractures. The purpose of the present video article is to review the indications for operative treatment of transitional ankle fractures in adolescents and to detail the surgical technique specifically for open reduction and screw fixation of triplane fractures. The procedure is performed in order to provide anatomic reduction of the fracture and rigid fixation. DESCRIPTION: Surgical treatment of a triplane fracture is indicated if there is >2 mm articular displacement of the distal aspect of the tibia or if the fracture pattern is deemed unstable following closed reduction and casting. Preoperative planning (Step 1) involves the use of radiographs and computed tomography scans to determine accurate fracture classification, the intended reduction maneuver, possible blocks to reduction, and screw trajectory and length. Room setup and patient positioning (Step 2) include placing the patient in the supine position with a bump under the hip, as well as the placement of a ramp or stack of blankets under the affected limb and adequate general anesthesia with muscle relaxation to facilitate reduction. Incision and surgical exposure (Step 3) is performed with use of an anterior ankle incision at the anatomic plane between the extensor hallucis longus and extensor digitorum longus, protecting the neurovascular bundle (i.e., the anterior tibial artery and deep peroneal nerve). Open reduction and assessment of reduction (Step 4) begins by removing any soft tissue, such as the periosteum, that may be interposed in the fracture site precluding a reduction. The ankle is then put through internal rotation and dorsiflexion in order to reduce the fracture, utilizing direct visualization through the incision and fluoroscopy to verify reduction with 2 mm articular displacement or >3 mm physeal displacement of the distal aspect of the tibia. Achieving and maintaining reduction with screw fixation within these tolerances helps decrease the chance of arthritis development by 5 to 13 years postoperatively(5,7). EXPECTED OUTCOMES: Following treatment of a triplane fracture with reduction and screw fixation, full ankle range of motion and normal growth are anticipated. Postoperative follow-up continues until skeletal maturity or until 1 year postoperatively with evidence of continued growth by Park-Harris lines on sequential radiographs. Short-term recovery is expected to be excellent, and long-term results are expected to be good as long as

Objective Aneurysmal bone cysts (ABC) are benign but locally aggressive lesions. Treating children with spinal ABC poses risks due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability after surgery. This study reports the updated outcomes of a uniform aggressive initial surgical technique for the treatment of spinal ABC in children. Methods Twenty-nine cases of spinal ABC were collected from a tertiary pediatric tumor center over a 24-year period (January 1990–September 2014). The study patients were divided into 2 groups based on the performed procedure: a traditional approach consisting of curettage and bone grafting (group 1) and a 4-step approach consisting of intralesional curettage, high-speed bur, electrocautery, and bone grafting (group 2). Results The study population was composed of 12 males and 17 females with a mean age of 12.2 years at the time of diagnosis and a mean postoperative follow-up of 4.03 years. Twenty-one patients underwent the 4-step approach, while 8 patients were treated with the traditional technique. The recurrence rate was 50% (4/8 patients) with the traditional technique (group 1) and 19% (4/21) in the 4-step technique (group 2) (P = .164). Regardless of the technique used, the presence of sensory symptoms at the time of presentation was a statistically significant factor for recurrence (P = .016). Conclusions We suggest that addressing spinal ABC in pediatric patients with a 4-step approach is a safe technique that may decrease long-term recurrence and reoperation rates compared to the traditional technique of intralesional curettage and bone grafting. Level of Evidence 4.

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

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

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

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

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

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

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

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

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

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

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

Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.

Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury.A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study.Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100).In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations.Level I prognostic study.

Forearm fractures occur commonly in children; however, there is still uncertainty on what leads to conversion from conservative to operative management. Patients who initially underwent closed reduction and casting for diaphyseal forearm fractures were evaluated for predictors of conversion to operative management. We found that the 20 of 124 (16%) patients in whom there was conversion to operative management were significantly older (11.1 vs. 5.7 nonoperative), had less angulation in the anterior-posterior (or coronal) plane (20.2 vs. 12.8° for the radius, 17.5 vs. 7.8° for the ulna), had a more proximal ulnar fracture location, and had more translated or shortened radius fractures.

The cause of rotator cuff injuries in the young athlete has been described as an overuse injury related to internal impingement. Abduction coupled with external rotation is believed to impinge on the rotator cuff, specifically the supraspinatus, and lead to undersurface tears that can progress to full-thickness tears. This impingement is believed to be worsened with increased range of motion and instability in overhead athletes. A retrospective review of seven patients diagnosed with rotator cuff injuries was performed to better understand this shoulder injury pattern. The type of sport played, a history of trauma, diagnosis, treatment method, and outcome were noted. Six patients were male and one was a female. Baseball was the primary sport for four patients, basketball for one, gymnastics for one, and wrestling for one. The following injury patterns were observed: two patients tore their subscapularis tendon, two sustained avulsion fractures of their lesser tuberosity, one tore his rotator interval, one tore his supraspinatus, and one avulsed his greater tuberosity. Only four patients recalled a specific traumatic event. Three patients were treated with arthroscopic rotator cuff repair, three with miniopen repair, and one was treated with rehabilitation. Six of the seven patients returned to their preinjury level of sport after treatment. Rotator cuff tears are rare in the adolescent age group. The injury patterns suggest that acute trauma likely accounts for many rotator cuff tears and their equivalents in the young patient. Adolescents with rotator cuff tears reliably return to sports after treatment. The possibility of rotator cuff tears in skeletally immature athletes should be considered. The prognosis is very good once this injury is identified and treated.

Vascular anomalies are among the most common congenital abnormalities in infants and children. The management of vascular anomalies requires interdisciplinary care and collaboration between orthopaedic surgeons, general surgeons, plastic surgeons, interventional radiologists, dermatologists, oncologists, and child life specialists, leading to the establishment of vascular anomaly teams at tertiary centers. Vascular anomalies are a heterogeneous group of conditions, with similar clinical appearance but substantially different manifestations. The development of an appropriate classification system has helped to reduce confusion regarding terminology, thus improving diagnosis and management. There are two groups of vascular anomalies: (1) vascular tumors and (2) vascular malformations. Differentiating between these two types, and their subtypes, is essential because of their distinct natural history and treatment1. The goal of this review is to highlight the role of the orthopaedic surgeon in the approach and treatment of extremity vascular malformations and to discuss diagnostic strategies and management at a multidisciplinary level. We also review the most common associated syndromes seen in the orthopaedic practice, including Klippel-Trenaunay syndrome, Proteus syndrome, Maffucci syndrome, Gorham-Stout disease or syndrome, Parkes Weber syndrome, and Bannayan-Riley-Ruvalcaba syndrome. In 1863, Virchow was the first to classify vascular anomalies into groups on the basis of their histopathologic appearance2. However, this nomenclature was confusing and often led to misdiagnosis with consequent inappropriate treatment. Mulliken and Glowacki proposed a classification system based on biological behavior …

Sacrectomy may offer curative potential for primary sarcomas of the sacrum. However, it is unclear whether and to what extent sacrectomies achieve local control.We therefore determined the curative potential, walking ability, continence control, and quality of life for children after sacrectomy for primary bone sarcoma.We retrospectively reviewed eight children with high-grade primary bone sarcomas treated with sacrectomy. The average age of the patients was 14 years (range, 4-18 years). There were six Ewing sarcomas and two osteosarcomas. Five patients underwent partial and three underwent total sacrectomies with all resection margins free of tumor. We recorded local and distant recurrences, functional (Musculoskeletal Tumor Society [MSTS] score) and oncologic outcome (survival), walking ability, bladder and bowel control, independence, and reintegration in society. The average followup was 80 months (range, 54-204 months).Six patients were alive without evidence of disease at last followup. Three patients had metastases develop and two died of disease 3 and 25 months postoperative. MSTS scores among survivors averaged 17.5 points (range, 5-25 points). Seven of the eight patients were able to ambulate, two independently. All initially were incontinent, but at last followup, two were continent and two were incontinent only under stress. Complications occurred in seven of eight, five of whom required additional surgery.Despite the high incidence of neurologic deficits and complications, sacrectomy achieved local control in patients with high-grade bone sarcomas. Our observations suggest long-term survival and adequate quality of life are possible in the pediatric population.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Chance fractures or flexion-distraction injuries of the spine are uncommon in children. Previous reports have been limited to isolated case reports or very small retrospective series. This is the largest series reported in the English literature. Methods This was a multicenter retrospective review of pediatric Chance fractures treated at 3 large level-1 pediatric trauma centers. We analyzed the demographics, causes, circumstances, treatment, complications, and clinical outcome of 35 patients younger than 18 years old with a Chance fracture. We hypothesize that surgical treatment provides the best results. Results There were 20 females and 15 males, with an average age of 9 years (range, 1.6 to 17 y). The most common level of injury was at L2 and L3 (20/35). Fifteen children (43%) had a neurological deficit at the time of injury and only 8 fully recovered. One patient deceased before formal orthopaedic treatment. Patients were treated at the discretion of the surgeon and the surgically treated group (20/34) had greater initial kyphotic deformity (22 degrees) than those treated nonoperatively (14/34; 11.4 degrees) and less posttreatment residual kyphotic deformity (3.5 vs. 20 degrees, respectively). The complication rate related to treatment was 26% (9/34) and most complications in the nonoperative group were related to progression of kyphosis whereas in the surgical group most complications are related to discomfort over the hardware (4 patients). Fifteen children (43%) had neurological deficit at presentation, 7 did not fully recover, for an incidence of permanent neurologic deficit of 10% among restrained patients versus 42% for unrestrained patients. Twenty-one patients (62%) had a good final clinical outcome defined by no chronic pain or neurologic deficit, this represented 45% good outcome in the nonoperative group compared with 84% in the operative group (NS). Conclusions In this multicenter retrospective study, surgical treatment of Chance fractures in children seems to produce better clinical outcome, the appropriate use of restraints reduce the incidence of definitive neurologic deficit. Level of evidence Level 3, comparative study.

We report the case of a 13-year-old boy with bilateral distal femoral unicameral bone cysts (UBCs) associated with acquired generalized lipodystrophy. As opposed to congenital generalized lipodystrophy, cystic bone lesions in acquired generalized lipodystrophy are rare. After radiographic and histologic confirmation of the UBCs, we performed percutaneous intramedullary decompression, curettage, and grafting. UBCs can be an important manifestation of acquired generalized lipodystrophy. Cystic bone lesions appear to be less common in acquired generalized lipodystrophy than in congenital generalized lipodystrophy, and intramedullary adipose tissue loss may be a predisposing factor for the development of bone lesions in patients with acquired generalized lipodystrophy. When evaluating a patient with lipodystrophy, doctors should recognize the clinical course may include the development of UBCs.

Aneurysmal bone cysts are benign active or aggressive bone tumors that commonly arise in the long bones, especially the femur, tibia, and humerus and the posterior elements of the spine. Aneurysmal bone cysts affect all age groups but are more common before skeletal maturity (first two decades of life). They usually involve the metaphysis or metadiaphyseal region of long bones. Although juxtaphyseal lesions abutting the growth plate and extending into the epiphysis have been described, there is no report of an aneurysmal bone cyst entirely and primarily located in the epiphysis. We report on a 3-year-old boy who presented with an entirely contained aneurysmal bone cyst to the proximal tibial epiphysis. We discuss the clinical presentation, diagnosis, including imaging and pathology, and treatment. A review of the pertinent literature also is presented.

Bone tumors are rare in children. Most bone tumors tend to involve the areas of fastest growth. Lower extremity tumors are more common than upper extremity ones, however upper extremity bone tumors do occur and can have a negative impact in the child's activities. Luckily, most bone tumors seen in children are benign and can be effectively treated by means of observation or local control by surgery. In this article we review and discuss the diagnosis and management of the most common pediatric benign bone tumors seen in the upper extremities including unicameral bone cyst, aneurysmal bone cyst, fibrous cortical defect, non-ossifying fibroma, osteochondroma, osteoid osteoma and enchondroma.

Unicameral bone cysts are benign bone lesions commonly seen in pediatric patients. Several treatment methods have been described with variable results and high recurrence rates. We previously reported short-term success of a minimally invasive technique that includes combining percutaneous decompression and grafting with medical-grade calcium sulfate pellets. The purpose of this study was to review the additional long-term results with a minimum followup of 24 months (average, 37 months; range, 24–70 months). We identified 55 patients with an average age of 10.8 years (range, 1.3–18 years). Forty-one of 55 lesions occurred in the humerus and femur. Forty-four of 55 (80%) patients had a partial or complete response after initial surgery; of these, seven obtained a partial or complete response after a repeat surgery (cumulative healing rate, 94%). Two patients underwent a third surgery (cumulative healing rate, 98%). One underwent a third repeat surgery (cumulative healing rate, 100%). There were no major complications associated with the procedure. Two patients had a superficial infection that resolved with oral antibiotics. Although some patients required a repeat procedure, complete or partial response at a minimum 24 months’ followup was achieved in all patients. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Osteoblastoma is a rare benign and sometimes locally aggressive tumor with peak incidence in the second decade. None of the available series addresses specifically the differences in presentation, management, and outcome between the pediatric and adult patient populations. Methods The medical records and radiographs of all children diagnosed with osteoblastoma during a 17-year period were reviewed. We recorded demographic information, time until diagnosis, location, clinical and radiographic characteristics, treatment, complications, and outcome at a minimum 2-year follow-up (range, 2-5 years). Results Seventeen children met the inclusion criteria. There were 10 boys and 7 girls, with an average age at diagnosis of 11 years (range, 20 months-15 years). The average time delay between onset of symptoms and diagnosis was 6.5 months (range, 2 months-2 years). There were 7 lesions in the lower extremity, 5 in the spine, 4 in the upper extremity, and 1 in the sternum. Pain at the tumor site was present in all cases. Two of the 5 patients with spine lesion had scoliosis. All patients underwent open incisional biopsy with intraoperative frozen section. In 16 cases, this was followed by a 4-step approach (extended curettage, high-speed burring, electrocauterization of cavity wall, and phenol 5% solution). Four of the 5 patients with spine lesions had instrumented posterior spine fusion after tumor removal. Two patients were referred to our institution with recurrent lesion after surgery elsewhere. Only 1 (6%) of 15 children initially treated at our institution had recurrence. All recurrences occurred in children younger than 6 years; all were successfully treated with a 4-step approach. Conclusions Osteoblastomas can be successfully treated with a 4-step approach. Children younger than 6 years may have a higher likelihood of recurrence.

We report the case of a 41-year-old woman who presented with ipsilateral synchronous low-grade juxtacortical osteogenic sarcoma of the distal femur and low-grade intramedullary osteogenic sarcoma of the proximal tibia. The diagnosis and treatment and a review of the literature also are provided.

Osteochondromas are the most common benign bone tumor; nonetheless, the natural history is poorly understood as a result of the low threshold for resection and the fact that many of these lesions are asymptomatic and therefore never diagnosed. We report a case of spontaneous regression of a solitary osteochondroma and review the literature. We believe the likelihood of spontaneous regression should be better understood by orthopaedic surgeons and taken into account in the decision process of whether to remove osteochondromas surgically.