Introduction: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. Methods: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. Results: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort (P=0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site (P<0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P=0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. Conclusions: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. Level of Evidence: Level IV—retrospective case series.
Case: Synovial chondromatosis is a rare condition affecting synovial joints. It occurs uncommonly in the shoulder and is rare in the pediatric population. We present a case of a 13-year-old male patient with shoulder pain who was diagnosed with synovial chondromatosis and a posterior labral tear. He was treated with arthroscopic loose body removal, synovectomy, and posterior labral repair and recovered well from the surgery. Four years after the surgery, he developed pain in the same shoulder, but the cause of the pain was not investigated per the patient's decision. Conclusion: Synovial chondromatosis should be considered in pediatric patients presenting with shoulder pain and loss of function with potential for recurrence.
Background: Studies have demonstrated that pediatric patients have an increased risk of failure with allograft anterior cruciate ligament reconstruction (ACLR); however, there is no study investigating whether allograft ACLR may be safe in older adolescent patients who are not returning to competitive pivoting sports (ie, low risk). The purpose of this study was to assess outcomes for low-risk older adolescents selected for allograft ACLR. Methods: We performed a retrospective chart review of patients younger than 18 years who received a bone-patellar-tendon-bone allograft or autograft ACLR by a single orthopaedic surgeon from 2012 to 2020. Patients were offered allograft ACLR if they did not intend to return to pivoting sports for 1 year. The autograft cohort was matched 1:1 based on age, sex, and follow-up. Patients were excluded for skeletal immaturity, multiligamentous injury, prior ipsilateral ACLR, or concomitant realignment procedure. Patients were contacted to obtain patient-reported outcomes at ≥2 years follow-up, including single assessment numerical evaluation, surgery satisfaction, pain scores, Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Parametric and nonparametric tests were used as appropriate. Results: Of the 68 allografts, 40 (59%) met inclusion and 28 (70%) were contacted. Among the 456 autografts, 40 (8.7%) were matched and 26 (65%) were contacted. Two allograft patients (2/40; 5%) failed at a median (interquartile range) follow-up of 36 (12, 60) months. There were 0/40 failures in the autograft cohort and 13/456 (2.9%) among the overall autografts; neither were significantly different from the allograft failure rate (both P > 0.05). Two (5.0%) patients in the autograft cohort required manipulation under anesthesia and arthroscopic lysis of adhesions. There were no significant differences between cohorts for single assessment numerical evaluation, Lysholm, Tegner, pain, and satisfaction scores (all P > 0.05). Conclusions: Although ACL allograft failure rates remain nearly two times higher than autograft failure rates in older adolescents, our study suggests that careful patient selection can potentially bring this failure rate down to an acceptable level. Level of Evidence: Level III; retrospective matched cohort study.
Background: Opioid abuse and overdose are in epidemic range in the United States and medical prescriptions, including those for postoperative analgesia, are a large contributing source to this misuse. Our quality improvement initiative aimed to reduce the opioid prescribing of pediatric orthopaedic surgeons in the postoperative setting. The aim was to decrease the percentage of children with surgically treated supracondylar humerus (SCH) fractures who are prescribed opioid medications at discharge from a baseline of 40% to 10% within 6 months. Setting/Local Problem: The study took place at an urban level 1 trauma center at a children’s hospital. The orthopaedic team completed closed reduction and percutaneous pinning for SCH fractures over a 14-month baseline period. Forty percent of these patients were discharged with an opioid prescription. After assessing baseline prescription rates, a multidisciplinary team of health professionals developed a key driver diagram. Interventions: Primary interventions included orthopedic department-wide pain management education, reporting of prescription rates during monthly conferences, and provider-specific feedback. The primary measure was the percentage of patients prescribed opioids upon discharge following closed reduction and percutaneous pinning of Type II and III SCH fractures. As a balancing measure, we tracked the use of a 24-hour nurse triage line for pain-related follow-up in the intervention period. We used statistical process control to examine changes in measures over time. Results: The percentage of patients receiving opioid prescriptions upon discharge following surgically treated SCH fractures decreased from 40% to 8% over 5 months and sustained for an additional 16 months. Conclusions: Through provider education, feedback, and regular reporting, we decreased the number of pediatric patients with surgically treated SCH fractures that were discharged with any opioid prescription by 80% over 5 months while ensuring clinically adequate pain control.
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