Background: Supracondylar humerus (SCH) fractures are common and present with associated nerve injuries in 11% to 42% of cases. Historically, SCH fractures with neurological compromise warranted urgent surgical intervention. A recent study showed that treatment delay is acceptable in patients with isolated anterior interosseous nerve (AIN) injury. Though indications for urgent treatment are relaxing, no studies have evaluated the need for urgent surgical treatment for other nerve injuries associated with SCH fractures. The aim of this study was to determine if the timing of surgical intervention is related to the timing of neurological recovery in SCH fractures associated with any nerve injury. Methods: A retrospective review of 64 patients with surgically managed SCH fractures and concomitant neurological deficit on presentation was conducted at a single level 1 pediatric trauma hospital from 1997 to 2022. The relationship between the time to surgical intervention and the time to partial and complete nerve recovery was analyzed using linear regression. Results: Sixty-four patients with an average age of 6.9±2.0 years and an average time to surgery of 9.8±5.6 hours were analyzed. Sixty-two patients (97%) were followed to partial neurological recovery and 36 (56%) were followed to full neurological recovery. Neurological deficit included median [n=41 (64%)], radial [n=22 (34%)], and ulnar [n=15 (23%)]. Ten patients (16%) had isolated AIN injury. The average time to partial neurological recovery was 20±23 days and the time to full recovery was 93±83 days. There was a statistically significant relationship between time to partial neurological recovery and time to surgical intervention (P=0.02). There was no relationship between time to full neurological recovery and time to surgery (P=0.8). Conclusion: Earlier time to surgical intervention in pediatric SCH fractures with isolated nerve injury was associated with earlier partial recovery but not full neurological recovery. Prioritizing urgent surgery in these patients did not improve their ultimate neurological recovery. Level of Evidence: Therapeutic level III.

Background: Brachial plexus birth injuries (BPBI) occur in up 0.4 to 4.6 per 1000 live births. Weakness about the shoulder and development of glenohumeral joint contractures are common sequalae of BPBI. Shoulder function in children with BPBI is frequently assessed using the modified Mallet classification to evaluate upper extremity motion deficits. The purpose of this study was to assess the accuracy of the abduction, external rotation, and hand-to-mouth Mallet classification scores in children with BPBI using motion capture. Methods: A retrospective study of 107 children with BPBI who underwent motion capture assessment and Mallet scores on the same date were reviewed. Motion capture measurements were used to calculate humerothoracic elevation and external rotation joint angles in the abduction/hand-to-mouth and external rotation positions, respectively. The humerothoracic joint angles were converted to the corresponding Mallet scores. Discrepancies between the Mallet scores determined by clinicians and those determined by motion capture were assessed. Results: For abduction, 24.3% of Mallet scores were misclassified during clinical examination. Of the misclassified scores, 22 were overestimated by 1 point and 4 were underestimated by 1 point compared with motion capture. For external rotation, 72.9% of Mallet scores were misclassified during clinical examination. Only 5 patients had an HT elevation that was less than 40 degrees, with 4 of them (80%) having a Mallet hand-to-mouth score of 4. There were no differences in proportion of patients with HT elevation less than 40 degrees who had a Mallet score of 4 or a Mallet score less than 4. Conclusions: There was better agreement in global abduction Mallet scores compared with external rotation and hand-to-mouth Mallet scores. This difference was likely due to the complex compensatory strategies that patients employ while performing external rotation and hand-to-mouth positions. The inaccuracy of the clinically determined Mallet scores is alarming given that they are frequently utilized to assist with surgical indications and are commonly used as outcome measures. Level of Evidence: Level IV Case series

Introduction: Lateral humeral condyle (LC) fractures are the second most common pediatric elbow fractures. Traditionally, displaced fractures have been treated with open reduction although recent studies have demonstrated successful outcomes of closed reduction for similar injuries. This study investigates the outcomes comparing open and closed reduction in a large cohort of children with moderately displaced (Song classification types 1 to 4) lateral humeral condyle fractures. Methods: Retrospective data from patients aged between 1 and 12 years treated for lateral condyle fractures was collected from 6 academic level 1 trauma centers between 2005 and 2019. Data was collected on patient demographics, radiographic parameters, reduction type, type of hardware fixation, and fracture patterns. Complications recorded include infections, reoperations for nonunion, osteonecrosis, and elbow stiffness. Results: An initial 762 fractures were identified. After excluding Song 5 cases, a total of 480 fractures met inclusion criteria, with 202 (42%) treated with closed reduction and 278 (58%) treated with open reduction. Demographics and injury characteristics were similar across the 2 reduction cohorts. After propensity score matching, delayed healing (52% vs. 28%; OR: 2.88, 95% CI: 1.97-4.22; P<0.0001) and stiffness (22% vs. 10%; OR 2.42, 95% CI: 1.42-4.13; P=0.0012) were significantly higher in the open reduction group. No differences in the rates of infection or nonunion (3% CR and 1% OR) were noted between the 2 groups. Conclusion: This study demonstrates that moderately displaced lateral condyle fractures requiring open reduction are more likely to have elbow stiffness and delayed healing when compared with the ones treated with closed reduction. For these reasons, we propose attempting closed reduction techniques as the first line of treatment in moderately displaced lateral humeral condyle fractures (if anatomic articular reduction can be achieved) to attain better patient outcomes.

Background: The aim of this study was to determine whether height differences in the levels of the iliac crests and femoral heads on erect spinal radiographs can be used as indirect measurements for the screening and surveillance of limb length discrepancy (LLD) in patients with scoliosis. Methods: Whole body posteroanterior (PA) and lateral erect radiographs of patients with adolescent idiopathic scoliosis (AIS) were retrospectively reviewed. Patients with congenital, syndromic, and neuromuscular scoliosis were excluded. A direct measurement of each limb was taken from the highest point of the femoral head to the middle of the tibial plafond; any difference between the sides was recorded as the LLD. In addition, the PACS Software tool was used to measure femoral head height difference (FHHD) and iliac crest height difference (ICHD). Pearson’s correlation, linear regression, and Bland–Altman plots were used to determine the relationships between LLD and FHHD, and LLD and ICHD. Results: Radiographs of 141 patients (92 women, 49 men) with an average age of 12.0±2.65 years were analyzed. A strong correlation (r=0.730, P<0.001) was found between LLD and FHHD; the correlation between LLD and ICHD was weaker (r=0.585, P<0.001). The Bland–Altman analysis showed good agreements of LLD with FHHD and ICHD. Linear regression analysis predicted an LLD of ≤10 mm based on an FHHD of ≤11.5 mm or an ICHD of ≤15.3 mm. Conclusions: FHHD and ICHD on spinal PA radiographs can be used for the screening and monitoring of LLD in patients with AIS with FHHD being the preferred indirect measurement. These measurements are readily learned and quick to perform. The FHHD and ICHD can be measured on any erect scoliosis PA radiograph. Therefore, these proxy measurements can be used to screen and monitor for LLD in patients with AIS. Level of Evidence: Level III.

Background: Imaging has an essential role in the diagnostic workup of suspected pediatric spinal trauma. The most suitable imaging method is still being debated and needs to be considered regarding the patient, injury, and local resources. Magnetic resonance imaging (MRI) is often performed after computed tomography (CT) in case of neurological symptoms or suspected ligamentous disruption. However, it is unclear if the MRI yields significant additional value after CT if the spinal cord injury is not suspected and if the MRI could be used as the sole imaging modality in an emergency department. This study aimed to assess the diagnostic value of emergency MRI after CT in suspected spinal trauma in children and adolescents. Methods: The imaging data and medical records of patients 17 years of age and younger with emergency spinal CT and MRI over 8 years were retrospectively reviewed. The primary study outcome was the diagnostic accuracy of the 2 imaging modalities in detecting surgically treated spinal injuries. Results: The study population consisted of 100 patients. Computed tomography and magnetic resonance imaging demonstrated all 7 surgically treated injuries, although one of the injuries was initially missed with CT. Magnetic resonance imaging revealed more injuries, but none of the injuries visible on CT required surgical fixation. Magnetic resonance imaging was able to exclude unstable injuries in patients who had highly suspicious or unequivocal findings on CT. Conclusions: Magnetic resonance imaging and computed tomography were both highly accurate in detecting unstable pediatric spinal injuries requiring surgical treatment. Magnetic resonance imaging seems not to reveal additional unstable injuries after adequately interpreted spinal CT. Level of Evidence: Level III—retrospective observational study.

Background: While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons’ role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. Methods: Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. Results: A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. Conclusions: While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. Level of Evidence: Level II—Survey study.

Background: This study aimed to compare the effect of the ultrasound-guided bilateral and bilevel erector spinae plane block (ESPB) on pain scores, opioid requirement, intraoperative motor-evoked potentials (MEPs), and stress response to surgery expressed by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) versus standard analgesia methods following idiopathic scoliosis surgery. Methods: This was a prospective, double-blinded, randomized controlled trial. Sixty patients aged 10 to 18 years and physical status ASA 1 or 2 were randomized into 2 equal groups, each receiving an ESPB or sham block. The primary outcome was the pain scores (Numerical Rating Scale, NRS) within 48 hours after spinal correction and fusion surgery for idiopathic thoracic scoliosis. The secondary outcomes were total opioid consumption, NLR, and PLR levels at 12 and 24 hours postoperatively and intraoperative MEPs. Results: ESPB patients presented lower NRS scores, signifying less pain, at all time points (30, 60, 90, 120 min; and 6, 12, 24, and 48 h after surgery), all P<0.0001. The total opioid consumption, the incidence of nausea or vomiting, and the need for remifentanil and propofol during surgery were significantly lower in the ESPB group. The surgery-induced stress response expressed by NLR and PLR was considerably lower in the ESPB group. ESPB did not affect the intraoperative MEP’s amplitude. Conclusions: ESPB is effective for postoperative analgesia, can reduce opioid consumption in patients undergoing scoliosis surgery, and reduces the stress response to surgery. ESPB does not interfere with neuromonitoring. Level of Evidence: Level I.

Background: This study compared the 5-year outcomes of isolated proximal femoral varus osteotomy (FO) and combined proximal femoral varus and pelvic osteotomy (FPO) for the treatment of hip displacement in children with cerebral palsy (CP) in Sweden, focusing on the number of reoperations and residual hip displacement. Methods: The study included 163 children with a 5-year follow-up after FO or FPO in the national Swedish CP surveillance program, CPUP. Descriptive statistics and univariate and multivariate Cox regression analyses were used to identify whether the age at surgery, sex, Gross Motor Function Classification System level, CP dominant symptom, hip migration percentage (MP), type of surgery (unilateral/bilateral), and history of soft tissue hip surgery were related to the 5-year outcomes after surgery. Failure after hip surgery was defined as a skeletal reoperation involving the hip and/or MP >50%. Results: During the period 2001 to 2017, 163 children (65 girls) underwent 246 femoral and/or pelvic osteotomies (154 FO, 47 bilaterally; 92 FPO, 16 bilaterally) and had a 5-year follow-up; 95 and 74 children had ≥1 FO or FPO as the primary skeletal surgery, respectively. The mean preoperative MP (51%±18% for FO and 59%±17% for FPO, P=0.001) and age at surgery (6.2±2.5 years for FO and 7.3±2.8 years for FPO, P=0.014) differed between procedures. At the 5-year follow-up, 5 hips (5%) had reoperations and 5 hips (5%) had radiological failure among the 92 FPOs, and 33 (21%) had reoperations and 14 (9%) radiological failure among the 154 FOs. The difference in outcome failure rate was significant (P<0.001). Multivariate Cox regression analysis showed a lower risk for failure with FPO [hazard ratio (HR)=0.32, 95% CI: 0.15-0.68] compared with FO. A higher preoperative MP increased the risk for outcome failure (HR=1.21, 95% CI: 1.15-1.36 for each 5% increment). Conclusions: FPO had a higher mean preoperative MP but a lower 5-year outcome failure rate compared with FO. A higher preoperative MP was associated with an increased risk of failure. Level of Evidence: Level II—prospective comparative study.

Background: Total hip arthroplasty (THA) in teenagers is generally avoided. Nevertheless, recent THA procedures in a very young patient show improved functional outcomes and implant survival, resulting in lower revision rates. This review aims to present an overview of the available literature on THA in teenagers and to provide evidence to inform caregivers. Methods: In this systematic review, studies required a primary THA method and a teenage patient population. Studies must report at least one of the following outcome measures: functional outcomes, implant survival, and complications. In addition, demographic and surgical data were collected. Results: Sixteen studies were analyzed, including 2040 patients and 2379 hips, with an average 7.7-year follow-up. The mean patient age was 18 years, with an average revision rate of 11.7%. The overall average relative improvement of the 2 most frequently used patient-reported (functional) outcome measures were 84.3 and 92.3% at the latest follow-up. Prosthesis, or liner loosening, was the cause of revision in 50.2% of the cases. Loosening was the most frequent complication (14.8%), together with prosthesis/liner wear (14.8%). Cementless fixation (70.7%), ceramic-on-ceramic articulation (34.7%), and the posterior surgical approach (82.3%) were the most applied techniques. Conclusions: The functional outcomes after THA in teenagers improved at follow-up. The average revision rate is relatively high, especially in the pre-1995 studies, with post-1995 studies reporting similar revision rates to the adult patient group. Research to further improve implant survival as well as the ease of revisions in teenagers is needed. Level of evidence: Level III—systematic review.

Background: Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown. Purpose: The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI). Study design: A retrospective cohort study. Methods: A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated. Results: Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P<0.001). A higher BMI (24.87±6.95, P=0.03) was associated with valgus alignment. Conclusions: There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations. Level of Evidence: Level III.

Background: Congenital spinal anomalies represent a heterogeneous group of spinal deformities, of which only progressive or severe curves warrant surgical management. Only a limited number of studies have investigated the impact of surgery on the health-related quality of life and very limited data exists comparing these outcomes to healthy controls. Methods: A single surgeon series of 67 consecutive children with congenital scoliosis (mean age at surgery 8.0 y, range: 1.0 to 18.3 y, 28 girls) undergoing hemivertebrectomy (n = 34), instrumented spinal fusion (n = 20), or vertical expandable prosthetic titanium rib procedure (n = 13) with a mean follow-up of 5.8 years (range: 2 to 13 y). The comparison was made to age and sex-matched healthy controls. Outcome measures included the Scoliosis Research Society questionnaire both pre and postoperatively, radiographic outcomes, and complications. Results: The average major curve correction was significantly better in the hemivertebrectomy (60%) and instrumented spinal fusion (51%) than in the vertical expandable prosthetic titanium rib group (24%), respectively (P < 0.001). Complications were noted in 8 of 67 (12%) children, but all patients recovered fully during follow-up. Pain, self-image, and function domains improved numerically from preoperative to final follow-up, but the pain score was the only one with a statistically significant change (P = 0.033). The Scoliosis Research Society pain, self-image, and function domain scores remained at a significantly lower level at the final follow-up than in the healthy controls (P ≤ 0.05), while activity scores improved to a similar level. Conclusions: Surgery for congenital scoliosis improved angular spinal deformities with a reasonable risk of complications. Health-related quality of life outcomes improved from preoperative to final follow-up, but especially pain and function domains remained at a significantly lower level than in the age and sex-matched healthy controls. Level of Evidence: Level III, therapeutic.

Physician extenders and advanced practice providers (APPs) are now common in most adult and pediatric orthopaedic clinics and practices. Their utilization, with physician leadership, can improve patient care, patient satisfaction, and physician satisfaction and work/life balance in addition to having financial benefits. Physician extenders can include scribes, certified athletic trainers, and registered nurses, while APPs include nurse practitioners and physician assistants/associates. Different pediatric orthopaedic practices or divisions within a department might benefit from different physician extenders or APPs based on particular skill sets and licensed abilities. This article will review each of the physician extender and APP health care professionals regarding their training, salaries, background, specific skill sets, and scope of practice. While other physician extenders such as medical assistants, cast technicians, and orthotists/prosthetists have important roles in day-to-day clinical care, they will not be reviewed in this article. In addition, medical trainees, including medical students, residents, fellows, and APP students, have a unique position within some academic clinics but will also not be reviewed in this article. With the many different local, state, and national regulations, a careful understanding of the physician extender and APP roles will help clinicians optimize their ability to improve patient care.

Background: Congenital vertebral anomalies are a heterogeneous group of diagnoses, and studies on their epidemiology are sparse. Our aim was to investigate the national prevalence and mortality of these anomalies, and to identify associated anomalies. Methods: We conducted a population-based nationwide register study and identified all cases with congenital vertebral anomalies in the Finnish Register of Congenital Malformations from 1997 to 2016 including live births, stillbirths, and elective terminations of pregnancy because of major fetal anomalies. Cases were categorized based on the recorded diagnoses, associated major anomalies were analyzed, and prevalence and infant mortality were calculated. Results: We identified 255 cases of congenital vertebral anomalies. Of these, 92 (36%) were diagnosed with formation defects, 18 (7.1%) with segmentation defects, and 145 (57%) had mixed vertebral anomalies. Live birth prevalence was 1.89 per 10,000, and total prevalence was 2.20/10,000, with a significantly increasing trend over time (P<0.001). Overall infant mortality was 8.2% (18/219); 3.5% (3/86) in patients with formation defects, 5.6% (1/18) in segmentation defects, and 12.2% (14/115) in mixed vertebral anomalies (P=0.06). Co-occurring anomalies and syndromes were associated with increased mortality, P=0.006. Majority of the cases (82%) were associated with other major anomalies affecting most often the heart, limbs, and digestive system. Conclusions: In conclusion, the prevalence of congenital vertebral anomalies is increasing significantly in Finnish registers. Detailed and systematic examination is warranted in this patient population to identify underlying comorbidities as the majority of cases are associated with congenital major anomalies. Level of Evidence: Level III.

Introduction: Identifying risk factors associated with developmental dysplasia of the hip (DDH) is essential for early diagnosis and treatment. Breech presentation is a major DDH risk factor, possibly because of crowding of the fetus within the uterus. In multifetal pregnancy, fetuses are generally smaller than singletons, which may obscure the effect of breech presentation on fetal hips. Only a few studies have investigated the occurrence of DDH in multifetal pregnancies. In this study, we aimed to evaluate whether the breech presentation is a major risk factor of DDH in twin pregnancies. Methods: This retrospective study included 491 consecutive live births (after 23+0 weeks gestation) delivered through cesarean section with at least 1 baby with noncephalic presentation in single or twin pregnancies from April 2013 to October 2018. We analyzed the incidence of DDH and its associated factors, including sex, breech, and multifetal pregnancy, with a generalized linear mixed model. Results: The incidence of DDH was 12.5% in singleton with breech presentation, 9.8% in twin-breech presentation, and 0.7% in twin-cephalic presentation. Multivariate analysis showed that singleton-breech presentation (P=0.003), twin-breech presentation (P=0.003), and female sex (P=0.008) were independent risk factors for DDH. Conclusion: Breech presentation is an independent risk factor for DDH in twin pregnancies, although twin pregnancy itself is not an independent risk factor for DDH.

Background: New surgical techniques have challenged traditional guidelines for nonsurgical treatment in pediatric and adolescent distal forearm fractures. This study was performed to compare outcomes and costs between closed reduction with percutaneous pinning (CRPP) and closed reduction with casting in the treatment of complete distal forearm fractures in children 8 to 14 years old. Methods: A retrospective cohort study was performed of 175 displaced distal forearm fractures treated with 2 different methods in the emergency department of a children’s trauma center. One hundred and fourteen children were managed using CRPP. The remaining 61 were treated with closed reduction and casting. All patients had initial follow-up radiographs. The quality of reduction and the residual angulation in both the coronal and sagittal planes were recorded. Outcomes included the angulation after reduction, residual angulation at final follow-up, radiation exposure, total immobilization time, days absent from school, total costs, and postoperative complications. Results: The postreduction sagittal plane angulation was significantly lower in the CRPP group (P=0.037). While residual deformity between the groups at the 6-month final follow-up was not significantly different in either the sagittal or coronal planes (P=0.486, 0.726), patients in the nonoperative group received greater radiation than those in the operative group (P<0.001). Patients in the nonoperative group missed fewer classes and sustained lower costs (P<0.001, <0.001). The mean immobilization time in each group was not significantly different (31.4±4.4 vs. 32.8±5.9 d; P=0.227). Conclusions: Although the postreduction quality was a little better and radiation exposure was less in the CRPP group, there was no difference between the 2 groups in angulation, total immobilization time, or complication rates after 6 months. The cost and time absent from school of patients in the nonoperative group was significantly lower than in the operative group. There is no clear advantage to CRPP treatment on outcomes. Therefore, closed reduction and casting is recommended in complete distal forearm fractures of children 8 to 14 years old. Level of Evidence: Level III—therapeutic study.

Introduction: Adolescents undergoing pediatric orthopaedic surgery typically experience an uncomplicated postoperative course. However, adolescence represents a unique transition period from pediatric to adult physiology. As a result, the astute pediatric orthopaedic surgeon will be aware of unique medical and social scenarios which are relevant to adolescents during the perioperative course including the risk of venous thromboembolism (VTE), prevalence of mental health conditions, and rising use of electronic cigarettes or “vaping” to consume nicotine and cannibas. Discussion: Adolescents are at a greater risk of VTE after pediatric orthopaedic surgery. In particular, adolescent females with a family history of blood clotting disorders and those with a change in mobility after surgery should be considered for prophylaxis. The prevalence of adolescent mental health conditions including anxiety, depression, and behavioral issues is increasing in the United States. Higher levels of preoperative anxiety and the presence of mental health pathology are associated with slower recovery, higher levels of postoperative pain, and the increased likelihood for chronic pain. Several quick screening instruments are available to assess adolescents for preoperative anxiety risk, including the Visual Analogue Scale for Anxiety or the Amsterdam Perioperative Anxiety Information Scale. Unfortunately, electronic cigarettes have become increasingly popular for the consumption of nicotine and cannabis among adolescents. Preoperative use of combustive cigarettes (nicotine/cannabis) represents perioperative risks for induction/anesthesia, postoperative pain, and analgesia requirements and issues with delayed wound and fracture healing. Conclusions: VTE, underlying mental health conditions, and usage of nicotine and cannabis are clear detriments to the recovery and healing of adolescent patients following orthopaedic surgery. Therefore, standardized screening for adolescents before orthopaedic surgery is indicated to identify perioperative risk factors which have negative impacts on functional outcomes.

Background: While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population. Methods: A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized. Results: Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes. Conclusions: Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Introduction: The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients. Discussion: Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists. Conclusion: This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.

Introduction: Tibial shaft fractures are common injuries in the adolescent age group. Potential complications from the injury or treatment include infection, implant migration, neurovascular injury, compartment syndrome, malunion, or nonunion. Methods: Published literature was reviewed to identify studies which describe the management options, complications, and outcome of tibial shaft fractures in adolescents. Results: Acceptable alignment parameters for tibial shaft fractures have been defined. Operative indications include open fractures and other severe soft tissue injuries, vascular injury, compartment syndrome, ipsilateral femoral fractures, and polytrauma. Relative indications for operative treatment are patient/family preference or morbid obesity. Closed reduction and cast immobilization necessitates radiographic observation for loss of reduction over the first 3 weeks. Cast change/wedging or conversion to operative management may be required in 25% to 40%. Flexible nailing provides relative fracture stability while avoiding the proximal tibial physis, but the fracture will still benefit from postoperative immobilization. Rigid nailing provides greater fracture stability and allows early weight bearing but violates the proximal tibial physis. Plate and screw osteosynthesis provide stable anatomic reduction, but there are concerns with delayed union and wound complications related to the dissection. External fixation is an excellent strategy for tibia fractures associated with complex wounds but also requires observation for loss of reduction. Discussion and Conclusions: The majority of adolescent tibia shaft fractures can be successfully managed with closed reduction and cast immobilization. Unstable fractures that have failed cast treatment should be treated operatively. Flexible intramedullary nailing, rigid intramedullary nailing, plate and screw osteosynthesis, and external fixation are acceptable treatment options that may be considered for an individual patient depending upon the clinical scenario.

Background: Compassion is the deep feeling that arises when confronted with another’s suffering coupled with a strong desire to alleviate that suffering. Until recently, evidence was lacking as to whether compassion was innate, acquired, or modifiable. Because patients who experience compassionate health care report better clinical outcomes, an understanding of the science behind it may give rise to methods of incorporating compassion into clinical care delivery. Methods: A high-level summary of the social and neuroscience research was constructed. Results: Functional neuroimaging of empathy and compassion demonstrates neural networks involving the insula, cingulate, and prefrontal cortices suggesting neurological hard wiring for these emotional and cognitive experiences. Neuroscience and social science research evidence supports the presence of cognitive and/or emotional empathy in all individuals studied; that empathy and compassion can be taught; and that both internal and external factors influence their expression. Conclusions: Burnout may result when clinicians know what their patients need (thereby activating the empathy/pain neural pathways) but are unable to deliver that care (therefore inactivation of the compassion/reward neural pathways). Understanding the neuroscience underlying empathy and compassion informs practical programs that mitigate burnout and creates a more compassionate workplace.

Background: Fibular hemimelia is the most common deficiency involving the long bones. Paley classification is based on the ankle joint morphology, identifies the basic pathology, and helps in planning the surgical management. Reconstruction surgery encompasses foot deformity correction and limb length equalization. The SUPERankle procedure is a combination of bone and soft tissue procedures that stabilizes the foot and addresses all deformities. Methods: We retrospectively reviewed 29 consecutive patients (29 limb segments), surgically treated between December 2000 and December 2014. Among the 29 patients, 27 were treated with reconstructive procedures. Type 1 (8 patients) cases were treated with only limb lengthening, and correction of tibial deformities. Type 2 (7 patients) cases were treated by distal tibial medial hemiepiphysiodesis or supramalleolar varus osteotomy. In type 3 (10 patients) cases, the foot deformity was corrected using the SUPERankle procedure. Type 4 (2 patients) cases were treated with supramalleolar osteotomy along with posteromedial release and lateral column shortening. In a second stage, limb lengthening was performed, using the Ilizarov technique. In the remaining 2 patients (type 3A and type 3C), amputation was performed using Syme technique as a first choice of treatment. Results: The results were evaluated using Association for the Study and Application of Methods of Ilizarov scoring. Excellent results were obtained in 15 of 27 (55%) patients. Six (22%) patients had good results, 4 (14.8%) had fair results, and 2 (7%) had poor results. Mean limb length discrepancy at initial presentation was 3.55 cm (range: 2 to 5.5 cm) which significantly improved to 1.01 cm (range: 0 to 3 cm) after treatment (P=0.015). Conclusions: Our results and a review of the literature clearly suggest that limb reconstruction according to Paley classification, is an excellent option in the management of fibular hemimelia. Our 2-staged procedure (SUPERankle procedure followed by limb lengthening) helps in reducing the complications of limb lengthening and incidence of ankle stiffness. Performing the first surgery at an earlier age (below 5 y) plays a significant role in preventing recurrent foot deformities. Level of Evidence: Level IV.

Background: Slipped capital femoral epiphysis (SCFE) occurs at a rate of 1 in 10,000 to 20,000 children. Methods: A PubMed search was undertaken to evaluate recent SCFE literature. A convenience sample of articles were selected and summarized. Results: Most slips appear well tolerated long-term with ∼5% resulting in total hip arthroplasty (THA) at 20-year follow-up. Classic data reveals poor outcomes following closed reduction for treatment of SCFE. Improvements in intraoperative fluoroscopy and avoidance of pin penetration have reduced the rates of chondrolysis. Unfortunately, avascular necrosis remains a known risk in patients, occurring in 15% to 50% of patients following acute, unstable slips. This is the most common cause of THA in patients with SCFE. Rate of THA due to degenerative arthritis secondary to SCFE is more difficult to determine and occurs at a later age. Although realignment procedures to address anatomic abnormalities from SCFE have increased in popularity, it is unclear if this prevents degenerative arthritis and subsequently reduces the rate of THA. SCFE patients face an increased risk of disability and death due to their underlying medical comorbidities. Interventions for weight loss, blood pressure management, and lifestyle adjustments should be considered at the time of SCFE diagnosis. Conclusions: SCFE remains a challenging and common condition for pediatric orthopedists. Although innovative techniques have been proposed, long-term outcome data still supports in situ pinning for stable slips, and in situ pinning with capsular decompression for unstable slips to minimize the risk of avascular necrosis.

Background: Twenty percent of shoulder dislocations occur in people younger than 20 years old. Management of anterior shoulder instability in young patients remains an evolving and controversial topic. Herein we review the natural history of anterior shoulder dislocation in young patients. Methods: The English-language literature was searched for studies examining the natural history of pediatric and adolescent shoulder dislocation. Recurrent dislocation was the primary outcome of interest in most studies. Results: Most studies found that recurrent instability was likely in young patients. Several systematic reviews reported the recurrence rate for young patients to be >70%. Recurrent instability was likely to cause greater damage to the joint and may result in more extensive and costly surgery. Conclusions: Most studies agree that recurrent anterior shoulder instability is likely in young patients. Some authors advocate for consideration of early surgery in this high-risk population.

Background: The long-term effects of small limb length discrepancies have been poorly documented in the literature. References to low back pain, hip pathology, knee pathology, and foot problems abound in the popular literature. Health care providers frequently recommend the use of lifts for structural and functional limb length discrepancies, yet the natural history of limb length inequality as well as the effectiveness of treatments that may be recommended are obscure. The purpose of this paper is to document and evaluate the literature associated with small limb length discrepancies. Methods: A search of the English literature was carried out using PubMed to identify papers dealing with the effects of limb length discrepancies. Papers reporting only expert opinion or case reports were excluded. Results: Papers dealing with the natural history of limb length discrepancy as well as studies in which gait analysis was performed in patients with limb length discrepancy were identified. Only 10% of the population has exactly equal lower limb lengths. Approximately 90% of the population has a limb length discrepancy <1.0 cm. Hip and knee pathology is present in an increased number of patients with limb length discrepancies over 5 mm. Hip pathology is more often present in the long leg, knee pathology has been reported in various studies to be more common in either the long or short leg. Low back problems seem to be more common on the short side in patients with limb length discrepancies. A number of different compensatory mechanisms for limb length discrepancy have been identified during gait analysis. Conclusions: There seems to be a consensus that limb length discrepancies >2.0 cm are frequently a problem. There is some evidence that limb length discrepancies as little as 5 mm can lead to long-term pathology.

Background: Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury. Purpose: The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature. Methods: A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms “anterior cruciate ligament,” “pediatric” and/or “adolescent,” and “conservative” and/or “nonoperative treatment.” A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format. Results: Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event. Conclusions: The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.

Introduction: Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. Methods: The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. Results: Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. Conclusions: The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.

Background: In order to determine whether treatments are effective in the treatment of meniscus tears, it is first necessary to understand the natural history of meniscus tears. The purpose of this paper is to review the literature to ascertain the natural history of meniscus tears in children and adolescents. Methods: A search of the Pubmed and Embase databases was performed using the search terms “meniscus tears,” “natural history of meniscus tears,” “knee meniscus,” “discoid meniscus,” and “natural history of discoid meniscus tears.” Results: A total of 2567 articles on meniscus tears, 28 articles on natural history of meniscus tears, 8065 articles on “menisci,” 396 articles on “discoid meniscus,” and only 2 on the “natural history of discoid meniscus” were found. After reviewing the titles of these articles and reviewing the abstracts of 237 articles, it was clear that there was little true long-term natural history data of untreated meniscus tears nor whether treating meniscus tears altered the natural history. Twenty-five articles were chosen as there was some mention of natural history in their studies. Conclusions: There are few long-term data on untreated meniscal tears or discoid meniscus, or tears in children and adolescents. The literature suggests that there is a higher incidence of chondral injury and subsequent osteoarthritis, but there are many confounding variables which are not controlled for in these relatively short-term papers.

Background: Early-onset scoliosis (EOS) is defined as the diagnosis of a spinal deformity before the age of 5 years. It can be divided into idiopathic, neuromuscular/syndromic, and congenital etiologies. Methods: The literature on the natural history of EOS was summarized. Results: The natural history varies with the etiology of EOS. Idiopathic curves may benefit from early serial casting. The natural history of neuromuscular and syndromic scoliosis is highly dependent on the natural history of the underlying disorder. Congenital scoliosis has a variable prognosis depending on the location and extent of the congenital malformations. Conclusions: Treatment of children with EOS is customized to the particular disorder. While lack of treatment has been shown to lead to increased mortality, extensive early definitive fusion may lead to thoracic insufficiency. Delaying definitive surgery and the use of growing instrumentation may provide benefit in maintaining pulmonary health. Clinical Relevance: Potential disturbance of growth must be considered in the treatment of young children with scoliosis.

Optimal clinical decision making and surgical management of hip dysplasia in children with cerebral palsy (CP) requires an understanding of the underlying pathophysiology (pathomechanics and pathoanatomy), incidence, and natural history. The incidence of hip dysplasia in children with CP is directly related to the degree of motor impairment. A subluxated or dislocated hip in a child with CP can compromise the quality of life for both the child and their caregivers. The goal of this article is to highlight the events over the last 25 years that have had the greatest impact on the management of hip dysplasia in children with CP. It is my opinion that the 2 most significant advances during this time have been the development of a classification system based upon motor impairment (the Gross Motor Function Classification System), and the development of surveillance programs for hip dysplasia in children with CP. This article will contrast neuromuscular hip dysplasia with developmental dysplasia of the hip. It will be shown how the development and utilization of the Gross Motor Function Classification System has contributed to our understanding of the epidemiology and natural history of hip dysplasia in children with CP, and to the assessment of outcomes following surgical management. The impact of hip surveillance programs on early soft tissue surgeries, skeletal hip reconstructions, and the incidence of hip dislocations and salvage surgeries will be reviewed. Challenges in the implementation of hip surveillance programs in resource poor and decentralized health care delivery systems will be considered, and innovative approaches identified.

Although cubitus varus has been regarded as a purely cosmetic problem in the pediatric population, symptomatic elbow instability, and ulnar neuropathy from the mechanical axis malalignment have been reported in adults. This overview discusses the biomechanical axis disruption that leads to soft tissue and morphologic bony alterations in the elbow and offers a compelling argument for corrective osteotomy to treat pediatric cubitus varus.

Although the core principles of managing infantile Blount disease generally remain unchanged, treatment modalities have evolved over the years. Consensus has yet to be reached regarding the efficacy of bracing. Children with Blount disease commonly have advanced bone age, which may impact the timing and magnitude of (over) correction of angular deformity. Techniques of growth modulation, based on the tension band principle, continue to gain popularity. Although there are limited reports in the last decade on proximal tibial osteotomy for this developmental disorder, both acute and gradual correction remain viable treatment options in the appropriate setting. In certain older children (>7 y old) with advanced stages of the disease, a medial hemiplateau elevation combined with lateral proximal tibial hemiepiphysiodesis may be needed to address the epiphyseal deformity. Given the possibility of unpredictable proximal tibial physeal activity, all children with Blount disease should be followed at regular intervals till skeletal maturity. To provide sufficient granularity for pooled analyses and help establish evidence-based clinical guidelines, standardization of reporting clinical outcomes among children with Blount disease is encouraged.

Patients with arthrogryposis often require anesthesia for surgical procedures. Intubation can be challenging due to lack of visualization. Anesthetic maintenance is fairly routine. Pheripheral blocks are an important adjunct to postoperative pain management.

Lower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient’s greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.

Despite the increasing popularity of operative treatment in adolescent tibia fractures, casting remains a viable first-line treatment. Because the selection bias in published reports does not allow direct comparison between casting and flexible nail treatment of closed pediatric tibia fractures, it is unclear whether flexible nailing offers any advantages over casting. This overview discusses parameters of acceptable alignment, indications, techniques for successful reduction and casting, subsequent inpatient and outpatient management including wedging of casted tibia fractures, expected outcomes, and comparison of casting with flexible nailing. As with any orthopaedic procedure, careful attention to patient selection, indications, and detail facilitates successful cast treatment in this older pediatric population.

Surgical hip dislocation (SHD) is a versatile approach used to address both intra-articular and extra-articular pathology around the hip joint in both pediatric and adult patients. It allows anterior dislocation of the femoral head for direct visualization of the hip joint while preserving femoral head vascularity and minimizing trauma to the abductor musculature. Previously described indications for SHD include femoroacetabular impingement, deformity resulting from Legg-Calve-Perthes disease, slipped capital femoral epiphysis, periarticular trauma, benign lesions of the hip joint, and osteochondral lesions. In this review, we will describe current surgical techniques, indications, and clinical outcomes for SHD.

Background: Much attention has been given to the relationship between various training factors and athletic injuries, but no study has examined the impact of sleep deprivation on injury rates in young athletes. Information about sleep practices was gathered as part of a study designed to correlate various training practices with the risk of injury in adolescent athletes. Methods: Informed consent for participation in an online survey of training practices and a review of injury records was obtained from 160 student athletes at a combined middle/high school (grades 7 to 12) and from their parents. Online surveys were completed by 112 adolescent athletes (70% completion rate), including 54 male and 58 female athletes with a mean age of 15 years (SD=1.5; range, 12 to 18 y). The students’ responses were then correlated with data obtained from a retrospective review of injury records maintained by the school’s athletic department. Results: Multivariate analysis showed that hours of sleep per night and the grade in school were the best independent predictors of injury. Athletes who slept on average <8 hours per night were 1.7 times (95% confidence interval, 1.0-3.0; P=0.04) more likely to have had an injury compared with athletes who slept for ≥8 hours. For each additional grade in school, the athletes were 1.4 times more likely to have had an injury (95% confidence interval, 1.2-1.6; P<0.001). Conclusion: Sleep deprivation and increasing grade in school appear to be associated with injuries in an adolescent athletic population. Encouraging young athletes to get optimal amounts of sleep may help protect them against athletic injuries. Level of Evidence: Level III.

Background: Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review. Methods: PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically. Results: On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs. Conclusions: Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments. Level of Evidence: Level II.

Background: There are many different treatment methods for slipped capital femoral epiphysis (SCFE). It was the purpose of this study to review the results from the literature for different methods of SCFE treatment and on the basis of level of evidence determine the current best evidence treatment. Methods: A systematic review of the literature was undertaken. Treatment results were grouped into 2 categories. The first was all methods without surgical hip dislocation, and the second was all methods in which surgical dislocation was used. Results: For stable SCFEs without surgical dislocation, the best recommended treatment (mostly level IV) recommends in situ single screw fixation over multiple pin fixation, epiphysiodesis, osteotomy, or spica cast. For the unstable SCFEs without surgical dislocation (all level IV), the best recommended treatment is urgent reduction with decompression and internal fixation. For both stable and unstable SCFEs, the short-term small series in the literature (all level IV) does not demonstrate an advantage or improvement in outcomes compared with in situ single screw fixation for stable SCFE and urgent reduction, decompression, and internal fixation in unstable SCFEs. Conclusions: A systematic review of the literature recommends on the basis of level of evidence that the best treatment for a stable SCFE is single screw in situ fixation and for unstable SCFEs urgent gentle reduction, decompression, and internal fixation. Level of Evidence: Level IV, systematic review of level IV studies.

Purpose: The purpose of this study is to provide a summary of the absolute and the relative surgical indications for both closed and operative treatment of tibial shaft fractures. Methods: A literature review of the pertinent literature was undertaken, and a limited number of the most significant papers are cited. Recommendations are provided for fractures that are most likely to need surgical intervention and relative indications for fractures that may benefit from surgical stabilization. Results: Successful closed treatment can be achieved either by casting and conventional 3-point molding or by utilizing the Sarmiento technique of casting. Either technique depends on soft tissues to maintain bony alignment. The reported results are significantly improved after surgical stabilization after open tibial shaft fractures and tibial shaft fractures associated with ipsilateral femoral fractures. Relative indications for surgical stabilization include comminuted fractures, displaced fractures with an intact fibula, and displaced fractures in adolescents. Compartment syndrome remains the most significant early complication encountered when treating tibial shaft fractures in children and adolescents by either closed or surgical methods and should be considered in the face of pain out of proportion to the injury or increasing narcotic requirements. Conclusions: Tibial fractures are one of the more common injuries treated by orthopedic surgeons. Although most can be treated by closed techniques, certain fractures benefit significantly from surgical stabilization.

Physeal fractures of the distal tibia and fibula are common and can be seen at any age, although most are seen in the adolescent. An understanding of the unique anatomy of the skeletally immature ankle in relation to the mechanism of injury will help one understand the injury patterns seen in this population. A thorough clinical exam is critical to the diagnosis and treatment of these injuries and the avoidance of potentially catastrophic complications. Nondisplaced physeal fractures of the distal tibia and fibula can be safely treated nonoperatively. Displaced fractures should undergo a gentle reduction with appropriate anesthesia while multiple reduction attempts should be avoided. Gapping of the physis >3 mm after reduction should raise the suspicion of entrapped periosteum that will increase the risk of premature physeal closure. Open reduction of displaced Salter-Harris type III and IV fractures is critical to maintain joint congruity and minimize the risk of physeal arrest.

Children’s ankle fractures are the second most common growth plate fractures in humans and one of the top 10 reasons for pediatric orthopaedic hospital admissions. Because triplane and Tillaux fractures occur during the period of distal tibial physeal closure, they are considered transitional injuries. The distal tibial physis closes in a unique, asymmetric pattern (middle, then medial, and finally lateral), and it is the portion of the physis that is open at the time of injury that is vulnerable to fracture in this age group. Triplane and Tillaux fractures occur after supination external rotation and compression stress with unpredictable multiplanar fracture patterns. The fracture may appear different on different x-ray projections, making computed tomography mandatory to determine the number of fragments. Because most of these fractures are intra-articular, anatomic or near-anatomic reduction of the joint surface is recommended to minimize future posttraumatic ankle arthritis. Because these fractures occur at the end of growth, they rarely result in growth arrest.

The majority of pediatric finger fractures can be treated by closed means with expected excellent outcomes. However, a subset of fractures can turn “ugly,” with complications such as growth arrest, malunion, and joint dysfunction if not recognized and treated appropriately. The present paper discusses several fractures in a child’s fingers that can cause substantial problems if not recognized promptly, highlighting important themes in the evaluation and treatment of a child’s injured finger.

Background: Abnormal range of motion (ROM) is a common sign of pathology in the pediatric hip, yet there are little data in the literature defining what the normal hip ROM is in children. The purpose of this study was to establish normative values for hip ROM in children of varying ages. Methods: We performed an Institutional Review Board approved, prospective study of otherwise healthy patients receiving fracture care at our institution. Inclusion criteria were boys and girls aged 2 to 17, who were being treated for an isolated upper extremity injury and who had no underlying musculoskeletal condition, history of lower extremity injury, or other systemic diagnosis. All patients were evaluated with a standard measurement technique using the same double–long-armed goniometer. Supine abduction, adduction, and hip flexion were measured with care taken to stabilize the pelvis. Internal and external rotation in flexion were assessed with both the hip and knee flexed to 90 degrees. In the prone position, hip extension was recorded as was internal and external rotation in extension. Left and right measurements were averaged to produce a single data point for each index. On the basis of a power analysis (to detect a minimal detectable difference of 6 degrees), 2 separate cohorts of 23 patients were randomly selected for the assessment of intraobserver and interobserver reliability. Results: We measured 504 hips in 252 pediatric patients, including 163 boys and 89 girls. We found a decreasing trend in ROM for almost all indices with advancing age, although this decline was less apparent among girls. Intraobserver reliability demonstrated excellent agreement (intra class correlation coefficient>0.81) for all indices. Interobserver assessments revealed excellent agreement for abduction, external rotation in flexion, internal rotation in extension, and external rotation in extension. Substantial agreement (intra class correlation coefficient, 0.61 to 0.8) was found for adduction, flexion, extension, and internal rotation in flexion. Conclusions: Normative values for hip ROM in children of varying ages have been established with acceptable intraobserver and interobserver reliability. Level of Evidence: Level II (Diagnostic).

Background Despite considerable advances in the past few decades, there is no generally accepted “top theory or theories” of the etiology of adolescent idiopathic scoliosis (AIS). This article aims to provide an overview of the current main hypothetical “concepts” on the etiopathogenesis of AIS. Methods An extensive literature review on hypothetical concepts on the etiology and etiopathogenesis of AIS. Results Concepts of etiopathogenesis in AIS were summarized and highlighted under 6 subgroups: genetics factors, abnormalities in nervous system, abnormal skeletal growth, hormones and metabolic dysfunction, biomechanical factors, and environmental and life style factors. An integrative model on the etiopathogenesis of AIS is proposed. Conclusions The current knowledge is still fragmented and many fundamental questions have remained to be answered. In moving forward in the perusal of further advancement of our understanding of the etiopathogenetic mechanisms and future evidence-based prevention and management of AIS, multidisciplinary and multicenter innovative research collaboration is imminently important and necessary. Clinical Relevance With a relatively comprehensive review on the current understanding on the etiology and etiopathogenesis of AIS, the article would help to stimulate further innovative thoughts, research, and especially collaborative research in this area of great interest.

Growth in childhood and in puberty has a major influence on the evolution of spinal curvature. The yearly rate of increase in standing height and sitting height, bone age, and Tanner signs are essential parameters. Additionally, biometric measurements must be repeated every six months. Puberty is a turning point. The pubertal diagram is characterized by two phases: the first two years are a phase of acceleration, and the last three years is a phase of decelaration. Thoracic growth is the fourth dimension of the spine. Bone age is an essential parameter. Risser 0 covers two third of the pubertal growth. On the acceleration phase, olecranon evaluation is more precise than the hand. On the deceleration phase, the Risser sign must be completed by the hand maturation. A 30 degree curve at the very beginning of puberty has 100% risk of surgery. Any spinal, if progression is greater than 10 degree per year on the first two years of puberty the surgical risk is 100%.

A small subset of serious injuries to the pediatric elbow, deemed “TRASH” lesions, are easily missed on radiograph because of their benign appearance. These lesions however, represent a group of osteochondral injuries, which if treated insufficiently result in chronic long-term consequences. Epiphyseal separations, a displaced intra-articular medial condyles before ossification of the secondary center, capitellar shear fractures, radial head fractures with radiocapitellar subluxation and osteochondral fractures of the olecranon, radial head or distal humerus with joint incongruity comprise the group of “TRASH lesions”. These injuries are usually seen in children less than 10 years of age who sustain high-energy trauma. The challenge is a prompt diagnosis requiring a high level of suspicion and early additional imaging. Many of these injuries are displaced and unstable requiring anatomic reduction, internal fixation with or without soft tissue repair for further stability. These injuries when diagnosed late, missed completely or treated improperly without aggressive surgical care can result in long-term complications. Surgical reconstruction of the late presenting malunion is difficult.

Fractures of the distal radius account for 80 percent of pediatric forearm fractures. The rapid growth of the distal radial physis and the on-going transformation of the metaphysic explain the propensity for fractures in this location and the potential for fracture remodeling. Fractures of the distal ulna are less common and usually occur in conjunction with fractures of the distal radius. In general both injuries can be managed by closed treatment and casting. Indications for skeletal fixation and/or open reduction are discussed. Complications are infrequent but not insignificant and usually treatable with early recognition and appropriate intervention.

Acceptable alignment of forearm fractures in children is controversial. An initial attempt at closed reduction in the emergency department is appropriate for the majority of these injuries. Complex or unstable fractures and those that cannot be maintained in acceptable alignment are candidates for surgical intervention. As a general guideline, fractures with complete displacement will remodel satisfactorily. However, angulation may be more critical for preservation of forearm rotation. Up to 15 degrees angulation is recommended as maximum angulation for mid-shaft and distal-shaft fractures in children younger than 8 years old. But 10 degrees is recommended as the maximum acceptable angulation for older children and proximal shaft fractures. When malunion is greater than this, remodeling is unreliable but may occur for fractures with less than 20-30 degrees of angulation.