Background: Tibial tubercle avulsion fractures (TTAF) often require surgical reduction and stabilization. Traditional teachings recommend postoperative knee immobilization for 4 to 6 weeks; however, the necessity of these restrictions is unclear and the actual practice varies. This study's purpose was to: (1) retrospectively review operatively managed TTAFs at a single center to examine the spectrum of postoperative rehabilitation guidelines, and (2) compare the outcomes of patients based on the timing of initiation of postoperative knee range of motion (ROM). Methods: Operatively managed TTAFs treated at a single center from 2011-2020 were identified. Patients with polytrauma, associated lower extremity compartment syndrome, or treatment other than screw fixation were excluded. Patient demographics, mechanism of injury, Ogden Classification, associated injuries, operative technique, postoperative ROM progression, and time to release to unrestricted activities were collected. Patients were grouped based on the initiation of postoperative ROM as Early (< 4 wk, EROM) or Late ( ≥ 4 wk, LROM). Bivariate analysis was used to compare characteristics between these 2 groups. Results: Study criteria identified 134 patients, 93.3% (n = 125) of whom were male. The mean age of the cohort was 14.77 years [95% confidence interval (CI: 14.5 to 15.0]. Forty-nine patients were designated EROM; 85 patients were categorized as LROM. The groups did not differ significantly with regards to age, race, injury characteristics, or surgical technique. Both groups progressed similarly with regards to postoperative range of motion. Ultimate activity clearance was achieved at ~20 weeks postoperatively without differences between groups (P > 0.05). Four instances of postoperative complication were identified, all of which occurred in the LROM group. Conclusion: A broad range of postoperative immobilization protocols exists following the screw fixation of TTAFs. Across otherwise similar cohorts of patients undergoing operative treatment, initiation of knee range of motion before 4 weeks was without complication and provided equivalent outcomes to traditional immobilization practices. Given the clear benefits to patients and caregivers provided by the permission of early knee motion and the avoidance of casting, providers should consider more progressive postoperative rehab protocols following operatively treated TTAFs.

Context: The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004 to 2014. Interestingly, there are limited recent data on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19. Objective: Given the impact of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period. Design: Retrospective cohort study. Setting: This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016 to June 2021, with March 1, 2020 considered the “start” of the COVID-19 pandemic. Patients or Other Participants: Using CPT codes, patients 18 years old and younger who underwent ACLR surgery were identified. Interventions: None. Main Outcome Measures: Patient demographics and overall rates of surgery pre- and intra-pandemic were compared. Data were analyzed using bivariate, mixed model, and time series analyses. Results: A total of 24,843 ACLRs were identified during this time period. In total, 1,853 fewer surgeries were performed after March 2020 than expected given pre-pandemic trends. Examining demographics, intra-pandemic, there was an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. There was also a significant shift in the proportion of ACLRs by region, with increased surgeries performed in the Midwest and decreased in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant. Conclusions: Based on pre-pandemic trends, there were fewer patients than projected who underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

Background: Isolated fractures of the olecranon process of the ulna in pediatric patients with open physes are classically considered pathognomonic for osteogenesis imperfecta (OI). The purpose of this study was to distinguish the clinical manifestations of isolated olecranon fractures in patients with and without OI to help practitioners assess when further evaluation for OI may be necessary. Methods: All patients younger than 18 years old who were treated for an isolated olecranon fracture at a pediatric tertiary care center between 2009 and 2021 were identified. Patients without radiographs available for review, those with known skeletal dysplasia other than OI, and patients with multiple fractures (eg, polytraumas) or with concomitant dislocations were excluded. Of the 701 patients identified, 403 were included for analysis. Demographic variables, mechanism of injury, treatment type, and determination of OI diagnosis were collected. Patients with a previously confirmed diagnosis of OI or with genetic confirmation of OI following their fracture were designated as OI (+), and the remainder were designated OI (−). The Mann-Whitney U and χ2 tests were used to compare groups. Results: Of the 403 patients, the median age was 7.8 years (interquartile range 5.2 to 12.5), and 270 (67%) were male. There were 14 confirmed cases of OI (3.5%). The OI (+) and OI (−) groups did not differ significantly by age or sex (P>0.05). OI (+) patients were more likely to sustain an injury from low-energy mechanisms (86% vs. 32%, P<0.001), sustain displaced fractures (86% vs. 21%, P<0.001) and undergo operative treatment (86% vs. 20%, P<0.001), and to report a history of previous fracture (79% vs. 16%, P<0.001) than OI (−) patients. 36% of OI (+) patients sustained a second olecranon fracture during the study period; there were no subsequent olecranon fractures in the OI (−) group. Conclusions: Isolated olecranon fractures may not be pathognomonic for OI. However, orthopaedists must be vigilant about the possibility of OI in patients who sustain displaced, isolated olecranon fractures under low-energy mechanisms with a history of previous fracture(s). Level of Evidence: Level III.

Objectives Recreational swimming/diving is among the most common physical activities in US children and a significant cause of morbidity across the United States. This study updates the national epidemiology of diving-related injuries. Methods The Consumer Product Safety Commission's National Electronic Injury Surveillance System database was queried for patients aged 0 to 19 from 2008 to 2020 who presented to any of the 100 National Electronic Injury Surveillance System-participating emergency departments for a diving-related injury. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives. Results A total of 1202 cases were identified for analysis corresponding to a total national estimate of 37,387 diving related injuries during the period from 2008 to 2020 and a national incidence of 3.6 injuries per 100,000 population. Males accounted for 64% of injuries. The average yearly incidences of injury in the 10 to 14 and 15 to 19 age groups were identical at 5.8 per 100,000. Contact with the diving board or platform was the most common cause of injury (34%). Diving backwards or attempting a flip or handstand dive were associated with increased odds of sustaining an injury resulting from contact with the diving board or platform (odds ratio, 16.0 and 6.9, respectively). In 2020, the incidence of diving-related injury fell to 1.6 per 100,000 population. Conclusions Diving injuries are common in children and adolescents, especially in boys aged 10 to 19. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

Background: Running is a highly popular activity that fosters healthy lifestyle habits in athletes of all ages. Track and field is a popular competitive youth sport with injuries estimated at 0.84 per 1000 athlete exposures among high school athletes. Injury patterns have been noted to vary by age and differ from those sustained in adult runners. Prior work has examined the epidemiology of youth track and field and running related injuries, but data from the recent decade in the setting of increasing sport specialization and year-round participation is lacking. Purpose: To examine the evolving epidemiology of track and field and running related injuries prompting emergency department presentation. Methods: A retrospective review of data obtained from the National Electronic Injury Surveillance System (NEISS) database was performed identifying children 10-18 with injuries associated with the Track & Field/Running product code (5030) from 2008-2020. National injury estimates were calculated annually and overall. Descriptive statistics were utilized to summarize injury characteristics of the entire cohort. Annual injury estimates were calculated to identify trends over the study period, which included the 2020 season interrupted by the COVID-19 pandemic. Results: We identified 8,399 track and field associated NEISS cases occurring from 2008-2020 representing a national estimate of 271,788 injuries [95% Confidence Interval: 250,288 to 294,24]. The majority (52%) of injuries occurred among patients 15 to 18 years of age. Injuries occurred most frequently in the lower extremity (52%) and most commonly involved the ankle (17%) and knee (15%). Sprain/strains were the most frequent injury type (40%). The majority of patients (97%) did not require hospitalization. Injury estimates of each demographic and injury characteristic with 95% confidence intervals are reported in Table 1. There was a rising annual frequency of track and field injuries seen peaking in 2017 with a notable decline in 2020 during the COVID-19 pandemic. Conclusion: Track and field injuries requiring emergency department presentation appear to be increasing from prior study estimates, but demonstrate similar distribution of injury characteristics. Severe injuries requiring hospitalization remain rare. The majority of injuries involve the knee and ankle and involve older adolescents. This data provides meaningful data for providers caring for and counseling adolescent athletes. [Table: see text]

The purpose of this study was to estimate monthly and annual trends in youth sports-related injury over the years 2016-2020 using the National Electronic Injury Surveillance System (NEISS) database to measure the impact of COVID-19 on overall and sport-specific rates of injury. Children and adolescents (0-19 years) presenting to USA emergency departments with sport participation injury from 2016 to 2020 were identified. Descriptive statistical analyses were performed of injury patterns. An interrupted time series analysis was applied to estimate changes in injury trends during COVID-19. Proportional changes in injury characteristics during this period were examined. An estimated 5 078 490 sportsrelated injuries were identified with an annual incidence of 1406 injuries per 100 000 population. Seasonal peaks in injuries occurred during September and May. About 58% of injuries were associated with contact sports, such as basketball, football, and soccer, and the most common injuries were sprains and strains. After the pandemic onset, there was a statistically significant 59% decrease in national youth sports-related injuries compared with the average estimates for 2016-2019. While the distribution of injury characteristics did not appear to change, the location of injury appeared to shift away from school toward alternative settings. A significant reduction in youth sports-related injuries was identified in 2020 coinciding with the COVID-19 pandemic, persisting throughout the rest of the year. No changes in the anatomic or demographic distribution of injuries were identified. This study expands our epidemiologic understanding of youth sports-related injury trends and how they changed following the pandemic onset.

Background: The COVID-19 pandemic has had a tremendous impact on youth sports participation for children and adolescents in the United States. Prior work demonstrated that pandemic-related closures led to a significant reduction in pediatric sports-related injury in the first half of 2020. However, these trends have yet to be evaluated on a national level and during the latter half of the year when organized youth sports began to re-emerge. Purpose: To estimate monthly and annual trends in youth sports-related injury over the last 5 years using a national injury database in order to measure the impact of the COVID-19 pandemic on overall and sport-specific rates of injury. Methods: We retrospectively reviewed data from the National Electronic Injury Surveillance System (NEISS) database identifying children and adolescents (0-18yo) presenting to US emergency departments with sport participation product codes (Table 1). Cases associated with >1 product code were excluded. The monthly and annual frequency of sports-related injuries was estimated. Quasi-experimental interrupted time series analysis was performed using the period of March-December 2020 as a binary variable. Differences in total and sport-specific injury estimates were calculated with pre-and post-trend analysis of the interrupted time series. Results: Our study criteria identified 152,560 youth sports-related injury cases corresponding to a national estimate of 4,582,892 injuries from 2016-2020 (95% CI=4,420,534-4,745,250). The mean yearly estimate from 2016-2019 was 1,041,944 injuries [890,047-1,193,841]. An estimated 415,115 injuries [357,779-480,594] occurred in 2020. Seasonal peaks in September and May were identified. There was a statistically significant decrease in national youth sports-related injuries that coincided with the nationwide COVID-19 shutdown in March 2020 (56,945 [33,143-80,747] fewer monthly injuries (P < 0.0001)). From March-December 2020, an estimated 457,221 [388,450-525,992] fewer sports-related injuries occurred than would have been expected based on prior trends. Sport-specific analyses (Table 1) demonstrated the greatest reduction of estimated injuries from March-December 2020 occurred in basketball (137,772 fewer injuries [130,192-145,246]), football (123,345 fewer injuries [86,883-159,807]), and soccer (70,383 fewer injuries [65,849-74,919]). Estimates of injuries associated with wrestling, ice hockey, and cheerleading had the greatest proportional reduction during the March-December time period (99%, 93%, and 79% respectively.) Conclusion: There was a significant reduction in youth sports-related injuries in 2020 coinciding with the nationwide COVID-19 shutdowns in March 2020 and persisting throughout the remainder of the year. Reduced injury burden was most notable for contact sports including basketball, football, and soccer. [Table: see text][Figure: see text]

Background: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. Purpose: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. Results: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures ( P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures ( P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). Conclusion: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.