Providing emergency trauma care for children is an integral aspect of pediatric orthopaedics. This survey provides information on the attitudes and strategies of practicing pediatric orthopaedic surgeons in the face of decreasing manpower and increasing demand for such services.
The Gartland classification of pediatric supracondylar humerus (SCH) fractures is commonly used but inconsistently defined regarding type 1 and type 2 (posteriorly hinged) SCH fractures. This study examined the reliability of the anterior humeral line (AHL) index compared with the Gartland classification. Fifty consecutive SCH fractures on anteroposterior and lateral elbow radiographs in pediatric patients (age range, 18 months to 15 years) were classified by 11 observers (9 attendings and 2 residents) according to the Gartland classification (types 1, 2, and 3) and the AHL index (AHL0, AHL passes anterior to the capitellum; AHL1, anterior one-third capitellum; and AHL2, middle one-third capitellum), with recommendations for treatment (cast immobilization vs surgery). Five attendings repeated the evaluation 4 to 6 weeks later. Interobserver and intraobserver reliability were scored using kappa statistics. Interobserver agreement for AHL with AHL1 and AHL2 combined (AHL1/2) was substantial (kappa=0.68) and moderate (kappa=0.55) when differentiating between AHL1 and AHL2. Anterior humeral line intraobserver reliability was almost perfect (kappa=0.83). Overall interobserver agreement on Gartland fracture type was fair (kappa=0.36), with type 2 fractures having the lowest (kappa=0.27), and with substantial (kappa=0.71) intraobserver reliability. For treatment, the interobserver agreement was fair (kappa=0.39), with substantial intraobserver reliability (kappa=0.72). Observers agreed more when using the AHL index than when using the Gartland classification. Observers differed on the degree of extension in posteriorly hinged SCH fractures that requires closed reduction. The AHL index is a more consistent method than the Gartland classification in differentiating posteriorly hinged SCH fractures and may be useful in guiding treatment. [Orthopedics. 2018; 41(4):e502-e505.].
Background: Developmental dysplasia of the hip represents a spectrum of deformity. Residual dysplasia at 2 years of age is associated with an increased risk for osteoarthritis and functional limitations. We compared the prognostic value of 6-month imaging modalities and aimed to identify optimal diagnostic metrics for the prediction of residual dysplasia. Methods: After IRB approval, patients who underwent Pavlik treatment between 2009 and 2018 with 2-year follow-up were identified. Sonographs [ultrasound (US)] and radiographs (x-ray) were obtained at 6-month and 2-year-old visits. Dysplasia at 2 years was defined as an acetabular index (AI) > 24 degrees. Receiver operating characteristic curves were constructed to quantitatively compare the prognostic ability of US and x-raybased measures at 6 months. Youden's index [(YI) (values range from 0 (poor test) to 1 (perfect test)] was used to evaluate existing cutoffs at 6 months of age (normal measurements: alpha angle (AA) ≥ 60 degrees, femoral head coverage (FHC) ≥ 50%, and AI <30 degrees) relative to newly proposed limits. Results: Fifty-nine patients were included, of which 28.8% of patients (95% CI: 17.3 to 40.4%) had acetabular dysplasia at 2 years. After adjusting for sex, AA [Area under the Curve (AUC): 80] and AI (AUC: 79) at 6 months of age were better tests than FHC (AUC: 0.77). Current diagnostic cutoffs for AA (YI: 0.08), AI (YI: 0.0), and FHC (YI: 0.06) at 6 months had poor ability to predict dysplasia at 2 years. A composite test of all measures based on proposed cutoffs (AA ≥ 73 degrees, FHC > 62% and AI ≤ 24 degrees) was a better predictor of dysplasia at 2 years (Youden's index (YI): 0.63) than any single metric. Conclusions: The rate of residual dysplasia remains concerning. The 6-month x-ray and US both play a role in the ongoing management of the developmental dysplasia of the hip. The prediction of dysplasia is maximized when all metrics are considered collectively. Existing parameters were not accurate; We recommend the following cutoffs: AA ≥ 73 degrees, FHC > 62%, and AI ≤ 24 degrees. These cutoffs must be validated.
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