Eliminating rote postoperative radiographs for surgically managed pediatric supracondylar humerus fractures.

Background: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP).

Methods: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

Introduction: Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications.

The impact of public health lockdown measures during the COVID-19 pandemic on the epidemiology of children's orthopedic injuries requiring operative intervention.

Background: In March 2020, Ontario instituted a lockdown to reduce spread of the SARS-CoV-2 virus. Schools, recreational facilities, and nonessential businesses were closed. Restrictions were eased through 3 distinct stages over a 6-month period (March to September 2020).

Current Concept and Management of Spastic Hip in Children: A Narrative Review.

Cerebral palsy (CP) is a non-progressive motor condition that hinders the development of movement and posture. One of the common problems faced in CP is spastic hips, which can cause discomfort, deformity, and functional restrictions. This review article seeks to offer a thorough summary of the most recent methods for treating spastic hips in cerebral palsy patients.

Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis.

Background Context: Intraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown.

Purpose: We aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS.

Use of monopolar cautery in patient with a vagal nerve stimulator during neuromuscular scoliosis surgery.

It is a historic and common practice while performing spine surgery on patients with a VNS has been to have the patient's neurologist turn off the VNS generator in the pre-operative anesthetic care unit and to use bipolar rather than monopolar electrocautery. Here we report a case of a 16-year-old male patient with cerebral palsy and refractory epilepsy managed with an implanted VNS who had scoliosis surgery (and subsequent hip surgery) conducted with the use of monopolar cautery. Although VNS manufacturer guidelines suggest that monopolar cautery should be avoided, perioperative care providers should consider its selective use in high-risk instances (with greater risks of morbidity and mortality due to blood loss which outweigh the risk of surgical re-insertion of a VNS) such as cardiac or major orthopedic surgery.

Incidence of secondary interventions after early spica casting for diaphyseal femur fractures in young children.

Background: Children aged 6 months to 5 years with diaphyseal femur fractures are typically treated with spica casting, as recommended by the American Association of Orthopaedic Surgeons clinical practice guideline. We aimed to determine the incidence of secondary interventions after early spica casting for femur fractures in children aged 6 years or less.

Methods: This was a retrospective cohort study of patients aged 6 years or less with diaphyseal femur fractures treated with early spica casting at a single Canadian tertiary care, level 1 trauma pediatric centre between January 2005 and May 2015.

Pediatric Musculoskeletal Radiographs: Anatomy and Fractures Prone to Diagnostic Error Among Emergency Physicians.

Background: Pediatric musculoskeletal (pMSK) radiograph interpretations are common, but the specific radiograph features at risk of incorrect diagnosis are relatively unknown.

Objective: We determined the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians (EPs) reviewing pMSK radiographs.

Methods: EPs interpreted 1850 pMSK radiographs via a web-based platform and we derived interpretation difficulty scores for each radiograph in 13 body regions using one-parameter item response theory.

Fifth metatarsal fractures in skeletally immature patients do not need routine orthopedic surgeon assessment and follow-up.

Objectives: The aim of this study was to determine the rate of delayed or nonunion of fifth metatarsal fractures in skeletally immature patients. Using this information, we sought to develop an evidence-based clinical care pathway in order to mitigate unnecessary patient radiation exposure, costs to families, and costs to the health system.

Methods: We retrospectively reviewed the charts and radiographs of patients who presented to an academic tertiary-care paediatric hospital between 2009 and 2014 with isolated fifth metatarsal fractures.

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study.

Background: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently.

Methods: We conducted a retrospective population-based cohort study using ICES data.

A Target Population Derived Method for Developing a Competency Standard in Radiograph Interpretation.

Construct: For assessing the skill of visual diagnosis such as radiograph interpretation, competency standards are often developed in an ad hoc method, with a poorly delineated connection to the target clinical population.

Background: Commonly used methods to assess for competency in radiograph interpretation are subjective and potentially biased due to a small sample size of cases, subjective evaluations, or include an expert-generated case-mix versus a representative sample from the clinical field. Further, while digital platforms are available to assess radiograph interpretation skill against an objective standard, they have not adopted a data-driven competency standard which informs educators and the public that a physician has achieved adequate mastery to enter practice where they will be making high-stakes clinical decisions.

Supracondylar Humerus Fractures in Older Children: Success of Closed Reduction and Percutaneous Pinning.

Background: The incidence of supracondylar humerus (SCH) fracture declines and fracture types change as children grow. Optimal treatment method is unclear in older children. The aim of the study was to determine if fracture type and configuration of distal humerus fractures changes as patients approach skeletal maturity, and to assess the success of closed reduction and percutaneous pin (CRPP) in extra-articular SCH fractures in this transitional age group.

Tibial tuberosity ossification predicts reoperation for growth disturbance in distal femoral physeal fractures.

Purpose: Distal femoral physeal fractures (DFPF) can cause growth disturbance that requires further surgical intervention. The aim of this study is to determine if Tibial Tuberosity Ossification Stage (TTOS) at the time of injury predicts secondary surgery for growth disturbance in patients who have sustained a DFPF.

Methods: We retrospectively investigated all patients who had operative treatment for a DFPF at a single centre over a 17-year period.

Complications of type II supracondylar humerus fractures treated at a specialized paediatric centre.

Background: Supracondylar humerus (SCH) fractures are the most common operatively treated paediatric fracture in Canada. Previous literature describing the low-energy (Gartland type II) subtype reports varying complication rates from a variety of practice settings. We sought to examine complications of type II SCH fractures treated at a Canadian specialized paediatric centre.

Establishing Safe Zones to Avoid Nerve Injury in the Approach to the Humerus in Pediatric Patients: A Magnetic Resonance Imaging Study.

Background: The surgical anatomy of upper-extremity peripheral nerves in adults has been well described as "safe zones" or specific distances from osseous landmarks. In pediatrics, relationships between nerves and osseous landmarks remain ambiguous. The goal of our study was to develop a model to accurately predict the location of the radial and axillary nerves in children to avoid iatrogenic injury when approaching the humerus in this population.

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study.

Objectives: We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome.

Methods: This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED).

Training surgeons and the informed consent discussion in paediatric patients: a qualitative study examining trainee participation disclosure.

Background: The process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee's participation during the consent process has not been reported in the paediatric setting.

Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada.

Background: The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures may safely reduce the number of radiographs and follow-up assessments for children with these injuries. The study objective was to examine potential cost-savings of the SKPOP from the perspective of the Ministry of Health and Long-term Care (MOHLTC).

Methods: Two sets of resource profiles, based on direct health care costs were created for a cohort of patients treated at our institution: the first based on actual follow-up assessment values, and the other based on follow-up assessments according to the SKPOP.

Impact of web-based clinical practice guidelines on paediatric fracture clinics.

Background: In an effort to standardize management and reduce over-treatment of uncomplicated paediatric fractures, the Victorian Pediatric Orthopaedic Network and the Royal Children's Hospital, Melbourne, created publically available web-based paediatric fracture pathways. The aim of this study was to determine the impact of web-based fracture pathways on the clinic volume at a tertiary-care paediatric fracture clinic.

Methods: A comparative retrospective review was performed at a large, urban, tertiary-care children's hospital.

Do All Clavicle Fractures in Children Need To Be Managed by Orthopedic Surgeons?

Objectives: Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatric fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system.

Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed.

Do toddler's fractures of the tibia require evaluation and management by an orthopaedic surgeon routinely?

Objective: The majority of uncomplicated toddler fractures of the tibia (toddler's fractures) do not need an orthopaedic surgeon's intervention or follow-up. However, inexperienced emergency room physicians, general practitioners and orthopaedic trainees and surgeons understandably defer to a cautious approach of referral and subsequent frequent clinical and radiographic follow-up. An evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system.

Informal regionalization of pediatric fracture care in the Greater Toronto Area: a retrospective cross-sectional study.

Background: Operative management of pediatric fractures is an expected competency in the specialty of Orthopedic Surgery. However, specialized pediatric centres may be providing care for increasing numbers of patients with fractures previously treated at community hospitals. The primary objective of this study was to examine trends in presentation of children with fractures to a specialized pediatric centre.