Background: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). Purpose: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. Study Design: Cross-sectional study; level of evidence, 3. Methods: We performed an institutional review board–approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. Results: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury ( P < .001). There was a higher rate of lateral meniscal tears ( P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed ( P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. Conclusion: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. Methods: We performed an Institutional Review Board (IRB)approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P = 0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P = 1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P = 0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. Level of Evidence: Level III.

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Background: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. Purpose: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). Conclusion: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

Background: In response to the disruption that the COVID-19 pandemic caused to our health care system, our institution promptly implemented telemedicine to address the need for non-urgent, yet necessary, musculoskeletal (MSK) care. The aim of this paper is to outline the telemedicine strategies and infrastructure implemented by the Division of Orthopaedics at the Children’s Hospital of Philadelphia (CHOP). Our system can serve as an example of how to provide continued access to care in the setting of mandated office visit cancellations. Methods: The Division of Orthopaedics developed and rapidly implemented new tools to make the transition to telemedicine possible. This involved leveraging existing infrastructure to develop clinical decision support, a centralized training platform, and access to real time data for quality improvement.  Results: Our division now conducts over 50% of visits via telemedicine. In the first three weeks of telemedicine, established patients accounted for the largest proportion of these visits, and knee injuries were the most common diagnoses encountered. To improve patient and provider experience, CHOP distributed hospital-wide surveys. Preliminary results indicated high satisfaction with the telemedicine experience. Conclusion: The COVID-19 pandemic has required health care providers to rapidly implement telemedicine on a larger scale than ever before. Our approach allowed us to quickly adapt and continue providing care to our patients. We expect that the expansion of telemedicine will increase access to health care beyond the pandemic.