Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures.

OBJECTIVES: Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence. METHODS: A cross-sectional survey of practicing orthopaedic surgeon members of the Pediatric Orthopedic Surgeons of North America (POSNA) was conducted, using a 22-item online questionnaire, and distributed using a modified Dillman technique. Survey questions were derived from and validated by literature review, expert opinion, and pilot-testing on the targeted sample before implementation. RESULTS: Of the 826 eligible participants, 558 (67.6%) responded to the survey. Of these, 505 (90.5%) had completed a fellowship in pediatric orthopaedics, 335 (60.0%) worked in a university-affiliated setting, and 377 (67.6%) had been in practice for <20 years. Only 158/543 [29.1%; 95% confidence interval (CI), 25.28, 32.92] reported using a removable splint to treat buckle fractures of the distal radius; 32 (5.9%; 95% CI, 3.9, 7.9) and 8 (1.5%; 95% CI, 0.5, 2.5) would use such splints for minimally displaced greenstick and transverse fractures of the distal radius, respectively. For distal fibular avulsion fractures, 122 (22.5%; 95% CI, 19.0, 26.0) would use a removable splint; 57 (10.5%; 95% CI, 7.9, 13.1) and 28 (5.6%; 95% CI, 3.7, 7.5) would do so for nondisplaced Salter-Harris I and II fractures of the distal fibula, respectively. The most commonly reported perceived barriers to application of a removable device were concerns about patient compliance, potential complications, and possible medicolegal implications. CONCLUSIONS: Only a relatively small proportion of practicing POSNA use such splints for minor distal radius and distal fibular fractures. These data support the need for implementation of knowledge translation strategies (eg, education) targeted at all the stakeholders to encourage pediatric orthopaedic surgeons to change practice in keeping with the best evidence for these common and stable injuries. LEVEL OF EVIDENCE: Level II.

Rate, associated factors and outcomes of recurrence of Kawasaki disease in Ontario, Canada.

BACKGROUND: Previous studies on recurrence of Kawasaki disease (KD) have mostly been limited to Japan, which has an incidence of KD 8-10-fold higher than North America. The aim of the present study was to determine the rate of KD recurrence for patients in Ontario, to identify factors potentially associated with increased odds of recurrence, and to compare the clinical course and outcomes of index and recurrent KD episodes. METHODS: Review was undertaken of all patients with recurrence of KD identified in Ontario, Canada, from 1995 to 2006. All patients with recurrence of KD (defined as at least three clinical signs of KD in addition to fever ≥ 5 days), presenting ≥ 14 days after the return to baseline from the index episode were included. RESULTS: A total of 1010 patients were followed for 5786 patient-years. During this period a total of 17 recurrent episodes in 16 patients were identified at a median of 1.5 years after the initial episode (2 weeks-5 years). Rate of recurrence of KD was 2.9 episodes/1000 patient-years, which is higher than the expected annual incidence of KD in the same age group (26.2/100,000 per year). No factors associated with increased risk of recurrence were identified, perhaps due to the small number of events. Clinical course and outcomes of the index and recurrent KD episodes were similar. CONCLUSIONS: A previous history of KD should increase the index of suspicion for future episodes of KD to allow for rapid recognition, treatment and to achieve optimal outcomes.

Corticosteroid administration for patients with coronary artery aneurysms after Kawasaki disease may be associated with impaired regression.

INTRODUCTION: Corticosteroid administration in Kawasaki disease (KD) is controversial but accepted as treatment for patients who do not respond to initial treatment. The impact of corticosteroids on evolving coronary artery aneurysms (CAA) and future vascular remodelling is unknown. METHODS AND RESULTS: The clinical history of 80 patients (73% male; median age at diagnosis 2.2 years) seen from 1990 to 2008 with CAAs after KD were reviewed, 19 (24%) of whom received systemic corticosteroids in the acute phase (14 for ≤ 3 days, 5 for 4+ days). CAA z-scores were assessed at baseline, 2-3 months, and 1 year after the acute phase. Linear regression models adjusted for repeated measures were used to determine the association between change in CAA z-score over time and corticosteroid use, adjusting for patient age at diagnosis, gender, intravenous immunoglobulin use, total days of fever, albumin level, hemoglobin level and platelet count. RESULTS: The corticosteroid treated group had longer duration of fever in the acute phase (median 17 vs. 11 days, p=0.04). Adjusted CAA z-scores at diagnosis, 2-3 months and 1 year follow-up for CAA in the left anterior descending decreased (from +5.5 to +3.5 to +1.9) in those not treated with corticosteroids, but progressed for those treated with corticosteroids (from +7.4 to +17.5 to +15.8), regardless of duration of corticosteroid treatment. Similar results were noted for CAA of the right coronary artery and the left main coronary artery. CONCLUSIONS: The use of corticosteroids in the acute phase of KD for patients with evolving CAAs may be associated with worsening involvement and impaired vascular remodelling and warrants further study.

Diagnostic coding of abuse related fractures at two children's emergency departments.

OBJECTIVES: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. METHODS: Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. RESULTS: Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. CONCLUSION: Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s).

Long-term anticoagulation in Kawasaki disease: Initial use of low molecular weight heparin is a viable option for patients with severe coronary artery abnormalities.

Patients with severe coronary artery involvement after Kawasaki disease (KD) require long-term systemic anticoagulation. We sought to compare our experience with thrombotic coronary artery occlusions, safety profile, and degree of coronary artery aneurysm regression in KD patients treated with low molecular weight heparin (LMWH) versus warfarin. Medical records of all KD patients diagnosed between January 1990 and April 2007 were reviewed. Of 1374 KD patients, 38 (3%) received systemic anticoagulation, 25 patients received LMWH from diagnosis onward, 12 of whom were subsequently switched to warfarin, and 13 received warfarin from onset. The frequency of thrombotic coronary artery occlusions was similar between drugs. Severe bleeding was more frequent in patients on warfarin, but minor bleeding was more frequent for patients on LMWH. Patients on warfarin were at greater risk of underanticoagulation or overanticoagulation (defined as achieving an anti-activated factor X level or an international normalized ratio below or above target level) than patients on LMWH (P < 0.05). Maximum coronary artery aneurysm z-scores diminished with time for patients on LMWH (P = 0.03) but not for those on warfarin (P = 0.55). This study suggests that LMWH is a potentially viable alternative for patients, especially young ones, with severe coronary artery involvement after KD.