Intraobserver and Interobserver Reliability of Radiographic Analysis of Proximal Humerus Fractures in Adolescents.

BACKGROUND: Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. METHODS: Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. CONCLUSIONS: Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. LEVEL OF EVIDENCE: Level III-diagnostic.

Complications After Plate Fixation of Displaced Pediatric Midshaft Clavicle Fractures.

BACKGROUND: Operative treatment of displaced pediatric midshaft clavicle fractures has become increasingly popular, despite lack of evidence that surgical management leads to superior outcomes. Complications, such as plate irritation necessitating removal and wound infection, have been reported in adults. The purpose of this study was to evaluate complications after plate fixation of midshaft clavicle fractures in the pediatric population. METHODS: We retrospectively identified patients 10 to 18 years old who had undergone plate fixation of a displaced midshaft clavicle fracture between 2009 and 2014. Patients who had surgery for a malunion or nonunion, and patients with <6 months of follow-up were excluded. Demographic data, radiographic union, time to return to activity, and complications were recorded. Any complication that led to unplanned surgery was considered a major complication. RESULTS: We analyzed 36 patients (25 males, 11 females) with 37 fractures. The average age at surgery was 14.5±1.7 years and mean follow-up was 1.3±1.0 years. All of the fractures healed and average time to return to activity was 58±28 days. The overall postoperative complication rate was 86% (32/37): 59% (22/37) implant prominence or irritation, 16% (6/37) anterior chest wall numbness, 5% (2/37) superficial wound dehiscence or infection, 3% (1/37) refracture adjacent to the plate, and 3% (1/37) refracture after implant removal. The major complication rate was 43% (16/37). Fifteen patients underwent a second surgery for implant removal secondary to prominence or pain. One patient underwent revision open reduction and internal fixation after he sustained a refracture at the distal aspect of the plate that resulted in a painful nonunion. Only 1 patient had a refracture after implant removal and this was treated nonoperatively. CONCLUSIONS: Implant prominence or irritation is common after plate fixation of displaced pediatric midshaft clavicle fractures. A second surgery for implant removal may be necessary. Patients should be appropriately counseled regarding complications before plate fixation of midshaft clavicle fractures. LEVEL OF EVIDENCE: Level IV-therapeutic.

Intrathecal Morphine and Oral Analgesics Provide Safe and Effective Pain Control After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor. SUMMARY OF BACKGROUND DATA: Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics. METHODS: We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded. RESULTS: A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups. CONCLUSION: ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary. LEVEL OF EVIDENCE: 3.

A High Preoperative Pain and Symptom Profile Predicts Worse Pain Outcomes for Children After Spine Fusion Surgery.

BACKGROUND: Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes. METHODS: Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes. RESULTS: The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018). CONCLUSIONS: A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.

Paper #35: Comparison of EOSQ-24 and SRS-22 scores in Congenital Scoliosis.

EOSQ-24 has been validated in early onset scoliosis (EOS), including congenital scoliosis (CS), and is completed by the caregiver. SRS-22 has been validated in idiopathic scoliosis and is completed by the patient. This study demonstrated a strong correlation between EOSQ-24 and SRS-22 for patients with CS who completed both questionnaires. It may be appropriate for cognitively normal children with EOS due to CS to complete SRS-22.

Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration.

PURPOSE: Supracondylar fractures of the humerus are the most common fracture of the elbow in children. The purpose of this study was to evaluate, in terms of outcomes and complications, Gartland type III pediatric supracondylar humerus fractures treated at a pediatric level-one trauma center over a 7-year period, specifically addressing the impact of time to surgery on the incidence of complications and conversion to open reduction. METHODS: We retrospectively reviewed 297 pediatric patients that sustained a closed Gartland type III supracondylar humerus fracture treated between December 2004 and December 2011. The time to the operating room was calculated from the medical records for each patient. The outcome measures evaluated were operative time, conversion to open procedure, and perioperative and postoperative complications. RESULTS: In our study, there were 30 complications in 25 children (8.4%). Conversion to open reduction occurred in 28 children (9.4%). The time from the emergency department to the operating room was not significantly correlated with increased complications, increased operative time, or conversion to open reduction (p > 0.05). Crossed pinning resulted in an increased risk of overall complications [odds ratio (OR) = 2.6] and iatrogenic nerve injuries (OR = 9.3). Complications also occurred more commonly in boys (OR = 3.3) and in older patients (p = 0.0069) CONCLUSIONS: We found no significant correlation between the time to surgery and complications, operative time, or need for open reduction. These findings support the trend of treating Gartland type III supracondylar humerus fractures in a less urgent manner. In addition, our study supports the concept that cross pinning leads to more complications than lateral pinning, including an 8-fold increase in iatrogenic nerve injury.

Comparison of submuscular and open plating of pediatric femur fractures: a retrospective review.

BACKGROUND: Plate osteosynthesis is an accepted method of treatment of pediatric femur fractures. Historically, open plating has been used. Submuscular bridge plating has gained recent popularity due to the theoretical advantages of decreased operative time, decreased blood loss, and decreased risk for infection. The purpose of this study was to compare submuscular bridge plating to open plating of pediatric femur fractures. METHODS: We retrospectively reviewed 79 patients (80 treated femur fractures) between 1999 and 2011 that underwent either open plating (58 femur fractures) or submuscular bridge plating (22 femur fractures). The outcome measures evaluated were operative time, estimated blood loss, malunion, leg length discrepancy, time to union, infection, unplanned return to the operating room, and length of hospital stay after surgery. RESULTS: Among our outcome measures, there was no difference between the 2 groups in terms of operative time, leg length discrepancy, time to union, infection, or length of hospital stay after surgery. There was greater estimated blood loss in the open plating group (P≤0.0001) and greater rotational asymmetry in the submuscular bridge plating group (P=0.005). There was a trend of increased unplanned return to the operating room in the open plating group (5/58 vs. 0/22) although not statistically significant (P=0.32). CONCLUSIONS: Submuscular bridge plating and open plating seem to be equally viable options for the management of pediatric diaphyseal femur fractures. In this study, open plating had an increase in estimated blood loss and a trend of more unplanned returns to the operating room, whereas submuscular bridge plating had an increase in asymptomatic rotational asymmetry. Further larger, prospective, randomized studies are necessary to further evaluate these operative techniques. LEVEL OF EVIDENCE: Therapeutic Level III.