Pediatric Septic Arthritis.

Acute septic arthritis is a condition with the potential for joint destruction, physeal damage, and osteonecrosis, which warrants urgent identification and treatment. The organism most frequently responsible is Staphylococcus aureus; however, our understanding of pathogens continues to evolve as detection methods continue to improve. MRI has improved our ability to detect concurrent infections and is a useful clinical tool where available. The treatment course involves intravenous antibiotics followed by transition to oral antibiotics when clinically appropriate. The recommended surgical treatment of septic arthritis is open arthrotomy with decompression of the joint, irrigation, and debridement and treatment of concurrent infections.

The TeamSTEPPS Approach to Safety and Quality.

Despite advances in patient safety since the landmark Institute of Medicine Report To Err is Human was published, adverse events and medical errors remain a persistent problem throughout health care. Safety experts have examined the practices in high-risk industries that maintain outstanding safety records for strategies to address the problem. Those efforts led to the development of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), a patient safety program that incorporates the principles of crew resource management and teamwork successfully used by industry into the health care setting. Evidence supports that the knowledge, skills, and attitudes, that comprise the core of TeamSTEPPS program, can improve safety and outcomes when used by members of the health care team. Successful implementation should assist the transition of health care workers from functioning as individual experts to performing as members of expert teams.

Emergency department on-call status for pediatric orthopaedics: a survey of the POSNA membership.

BACKGROUND: The emergency room on-call status of pediatric orthopaedic surgeons is an important factor affecting their practices and lifestyles and was last evaluated in 2006. METHODS: The entire membership of the Pediatric Orthopaedic Society of North America (POSNA) was surveyed in 2010 for information regarding their emergency room on-call status with 382 surveys returned of over 1000 e-mailed to members of POSNA. Detailed information about on-call coverage, support, and frequency was obtained in answers to 14 different questions. RESULTS: Compared with the prior survey in 2006, the 2010 survey indicated that a higher percentage of pediatric orthopaedic surgeons receive compensation for taking emergency room call; a higher percentage cover pediatric patients only when on-call; and accessibility to operating rooms in a timely manner for trauma cases, although limited, has improved for pediatric patients. Utilization of support staff to meet on-call trauma coverage demands, such as residents, physician's assistants, and nurse practitioners, is becoming more common. CONCLUSIONS: Concentration of pediatric orthopaedic trauma has increased the coverage demands on pediatric orthopaedists. This has resulted in a change in reimbursement strategies, and allocation of OR time and hospital staffing resources.

Preventable childhood injuries.

BACKGROUND: This is a literature review generated from The Committee on Trauma and Prevention of Pediatric Orthopaedic Society of North America to bring to the forefront 4 main areas of preventable injuries in children. METHODS: Literature review of pertinent published studies or available information of 4 areas of childhood injury: trampoline and moonbouncers, skateboards, all-terrain vehicles, and lawn mowers. RESULTS: Much literature exists on these injuries. CONCLUSIONS: Preventable injuries occur at alarming rates in children. By arming the orthopaedist with a concise account of these injuries, patient education and child safety may be promoted. LEVEL OF EVIDENCE: 3.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Impact of fractures on school attendance.

BACKGROUND: The purpose of this study was to determine the average prevalence of children across the nation who experience difficulty in attending school after an acute orthopaedic injury. METHODS: A survey was created to obtain information on school absence for children with acute orthopaedic injuries. All members of the Pediatric Orthopaedic Society of North America were invited to complete the survey. RESULTS: The survey was sent by e-mail to 936 members of the Pediatric Orthopaedic Society of North America. A total of 283 surgeons from 45 states responded to the survey, which resulted in a response rate of 30.2%. The survey found a correlation with difficulty in attending school with a cast and the size of the population served. Communities with the larger populations are less likely to permit children to attend school with a cast. The most common reasons given by schools for a child not being permitted to attend school with a cast were concern for the safety of the child and inability to accommodate the needs of the child. CONCLUSIONS: Most physicians participating in the survey reported no difficulty with their patients attending school with a cast. There was more difficulty with children in attending school with a cast in metropolitan areas and in communities with greater than 1 million people. To decrease or to eliminate absence from school, it may be best to identify schools in a physician's community that do not allow attendance of children with a cast. Once individual schools are identified, advocacy can be targeted. At the very least, when it is known which schools are involved, the surgeon can anticipate difficulties and plan accordingly. As a child's absence from school has substantial negative consequences, we strongly support intervention to enable injured children to appropriately return to a regular educational setting in a timely manner. Future studies with school participation would help to identify reasons for school absence after a musculoskeletal injury. LEVEL OF EVIDENCE: Level V, Prognostic.

Medical errors in orthopaedics. Results of an AAOS member survey.

BACKGROUND: There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts. METHODS: Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months. RESULTS: A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%). CONCLUSIONS: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).

Immediate single-leg spica cast for pediatric femoral diaphysis fractures.

PURPOSE: Immediate spica cast application is the standard of care for young children with isolated femur fractures. We evaluated the outcomes and function of children treated with single-leg spica casts. METHODS: We performed a retrospective review of 45 children treated with single-leg spica casts. Demographic data, mechanism of injury, hospitalization time, time in cast, and complications were collected by chart review. Children returned for a physical examination and radiographs. Subjects completed a questionnaire about the child's functional level and the Activities Scale for Kids. RESULTS: There were 33 boys and 12 girls. The average age was 3.3 (9 months to 9 years). The mechanism of injury was a fall in 71%. The mean hospitalization was 1 day (0-4 days) and the mean time to union was 6 weeks (4-9 weeks). Ninety-five percent of the patients crawled in the cast, 90% pulled to stand, 81% cruised, and 62% walked either independently or with assistive devices. One half of the patients in school or daycare returned while in the cast. Two children failed because of unacceptable shortening. Two children required repeat reductions under anesthesia due to unacceptable alignment. Five casts broke at the hip joint. At final review, there was 1 rotational malunion. There were no radiographic malunions. The median Activities Scale for Kids score was 95 of 100 possible points. CONCLUSIONS: The single-leg spica can safely, effectively manage low-energy femur fractures in young children. SIGNIFICANCE: The single-leg spica may address some of the social concerns associated with the use of a spica cast for simple femur fractures.

Communication skills.

Surveys of American Academy of Orthopaedic Surgeons members and patients indicate that orthopaedic surgeons are "high tech, low touch." According to patients and colleagues surveyed, orthopaedic surgeons are given high ratings by patients and colleagues for their skills in the operating room, but their listening and communication skills can be improved upon; they could listen better and show more empathy for their patients. Communication affects patient satisfaction, adherence to treatment, and physician satisfaction. Communication problems have also been cited as the most common factor in the initiation of malpractice suits. All orthopaedic surgeons can benefit from improving their communication skills.

Compartment syndrome in children and adolescents.

BACKGROUND: The authors performed a computerized search of the National Pediatric Trauma Registry for all patients who had compartment syndrome during a 51-month period. METHODS: One hundred thirty-three cases were identified. Boys outnumbered girls 4 to 1. The median age was 12 years and the peak incidence was in the 10- to 14-year-old age group. RESULTS: The most common mechanisms of injury were pedestrians struck by motor vehicles, falls, sports, and occupants in motor vehicle crashes. Eighty-five percent of the cases were the sequelae of fractures. Forearm fractures were the most common cause in the upper extremity, and tibia and/or fibula fractures were most common in the lower extremity. CONCLUSIONS: Open fractures significantly increased the risk of developing a compartment syndrome for both forearm and leg fractures. Sixty percent of the patients went directly from the emergency room to the operating room, suggesting that the others developed the compartment syndrome after admission, or had delayed diagnosis.

Bilateral femoral neck fractures after pelvic irradiation.

Our patient, who had no history of trauma, developed bilateral femoral neck fractures several years after pelvic irradiation. The well-documented sequelae of femoral neck fractures include avascular necrosis, nonunion, and malunion. Postirradiation pelvic pain, particularly in the absence of trauma, should be aggressively evaluated. With high clinical suspicion and normal plain radiographs, MRI can be used to exclude potentially serious fractures.

Mangled extremity severity score in children.

Treatment of the severely traumatized or mangled lower extremity poses significant challenges. The Mangled Extremity Severity Score (MESS) is a scale that uses objective criteria to assist with acute management decisions. Most research on the MESS has been in adults or combined series with few children. The study was performed to investigate the MESS in children exclusively. The MESS was applied retrospectively to 36 patients with grades IIIB and IIIC open lower extremity fractures collected from two level 1 pediatric trauma centers. Patients were divided into limb salvage and primary amputation groups based on the decision of the treating surgeon. In the salvage group there were 18 grade IIIB fractures and 10 grade IIIC fractures. The MESS prediction was accurate in 93% of the injured limbs. In the amputation group eight limbs met the inclusion criteria; the MESS agreed with the treating surgeon in 63% of cases. These findings suggest the MESS should be considered when managing a child with severe lower extremity trauma.