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Proximal humeral fractures are relatively common in pediatric patients. These injuries are usually treated nonoperatively in younger children or children with minimally displaced fractures. However, closed reduction or open reduction followed by percutaneous pinning is recommended for older children with displaced fractures. Percutaneous pinning has several advantages, but there are limited reports of a safe and reliable surgical technique in the literature. Patients are positioned in a modified beach-chair position to allow orthogonal imaging. The injured extremity is draped free from the remainder of the body. Closed reduction, which comprises a combination of traction, abduction, and rotation, is attempted. Internal or external rotation may be required, depending on the fracture line and deforming forces. If an anatomic closed reduction cannot be obtained, a block to reduction should be suspected and open reduction should be performed via a deltopectoral approach. Once the fracture is reduced, two 2.5-mm threaded Kirschner wires from the small external fixator set are used to percutaneously fix the fracture. Any small external fixator set can be used, and if not available, individual threaded wires of similar size can be used. Alternatively, Kirschner wires can be advanced to the fracture site prior to reduction and then advanced into the humeral epiphysis once the fracture is reduced. Care is taken to avoid the axillary nerve, which is reliably within 6 cm of the anterolateral aspect of the acromion, and wires are placed distal to this site. Once pin position has been confirmed radiographically, the construct is secured with pin-to-pin clamps to improve rigidity and further decrease the risk of pin migration. A soft dressing and shoulder immobilizer are placed postoperatively. Patients are followed with biweekly radiographs, and pins are removed in the outpatient office or under conscious sedation at 4 weeks. Leaving pins for a longer period may increase the risk of skin irritation and potentially infection. Alternatives to closed reduction or open reduction and percutaneous pinning include nonoperative management and elastic intramedullary nailing. Nonoperative treatment is a reliable option for most patients. However, it is not suitable for older children with severely displaced fractures because of diminished remodeling potential. Elastic intramedullary nailing is a good option for distal fractures. However, it is not suitable for proximal fractures, and it has been associated with longer operative times and more blood loss than percutaneous pinning. It also requires a second procedure. This procedure allows for anatomic fixation of proximal humeral fractures and provides a rigid construct to maintain reduction. It is not technically challenging, requires limited postoperative immobilization, and decreases the risk of a second general anesthetic.

Injuries in pediatric and adolescent athletes continue to rise in the United States, with increases in year-round sports participation, earlier sport specialization, and inadequate access to neuromuscular training programs. In this setting, the use of magnetic resonance imaging (MRI) provides a critical diagnostic tool. This review article describes the utility of MRI in diagnosing common pediatric and adolescent sports injuries and presents imaging findings associated with these pathologies. [ABSTRACT FROM AUTHOR]

Purpose: There are various anatomic risk factors for patellofemoral instability (PFI) that help guide surgical treatment, including the tibial tubercle to trochlear groove (TT‐TG) distance. However, no study has analysed the temporal changes in TT‐TG prior to surgical intervention. This study sought to understand the variations in TT‐TG over time for pediatric patients suffering from PFI prior to surgical intervention. The authors hypothesised that the TT‐TG would substantially change between time points. Methods: Patients undergoing medial patellofemoral ligament (MPFL) reconstruction between 2014 and 2019 by one of two fellowship‐trained orthopaedic surgeons were identified. Patients were included if they had two preoperative magnetic resonance imaging (MRI) performed on the same knee within 7.5 months of each other prior to any surgical intervention and had an initial TT‐TG greater than 10 mm. Results: After considering 251 patients for inclusion, 21 patients met the final inclusion criteria. The mean age was 14.5 ± 2.5 years and 61.9% were female. TT‐TG was initially noted to be 15.1 ± 1.8 mm. At mean time after sequential MRIs of 5.0 ± 1.9 months, TT‐TG was noted to be 16.7 ± 3.2 mm. The differences between initial and subsequent TT‐TG ranged from a 21.2% decrease to a 61.1% increase, with a mean difference of an 11.3% increase. Comparison between initial and subsequent TT‐TG values demonstrated a significant difference (p = 0.017). Change in tibiofemoral rotation ranged from −9.2° to 7.5°. When comparing the change in TT‐TG to change in tibiofemoral rotation, a significant correlation was found (p = 0.019). Conclusion: Despite only a mean time between MRIs of 5 months, variations in TT‐TG ranged from a decrease of 21.2% to an increase of 61.1%. The significant relationship between the changes in TT‐TG and changes in tibiofemoral rotation between MRIs suggest that TT‐TG measurements may vary due to variations in tibiofemoral rotation at the time of individual MRIs. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established.To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures.Cross-sectional study; Level of evidence, 2.A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions.A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence (P = .17) or grade (P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations (P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001).This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment. [ABSTRACT FROM AUTHOR]