Epidemiology of Pediatric Firearm Injuries in the United States: The Progression of Gunshot Injury Rates Through the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: Ballistic injuries among pediatric populations have become a public health crisis in the United States. The surge in firearm injuries among children has outpaced other causes of death. This study aims to assess the trend in pediatric gunshot injuries (GSIs) over the last decade and investigate the impact, if any, of the pandemic on GSIs statistics. METHODS: A comprehensive retrospective analysis was conducted using a federated, real-time national database. A total of 15,267,921 children without GSIs and 6261 children with GSIs between 2017 and 2023 were identified. The study evaluated the incidence and annual proportions of GSIs among different demographics. In addition, the incidence proportions per 100,000 for accidental, nonaccidental, fracture-related, and fatal GSIs were analyzed. RESULTS: The incidence proportions per 100,000 for GSIs, accidental GSIs, nonaccidental GSIs, fatal GSIs, wheelchair-bound cases, and fracture-related GSIs increased significantly from 2017 to 2023, going from 9.7 to 22.8 (Relative Risk: 2.342, 95% CI: 2.041, 2.687, P < 0.001). The overall increase was mostly a result of accidental GSI when compared with nonaccidental (incidence proportion 25.8 vs 2.1; P < 0.001) in 2021 at the height of the pandemic. In patients with an accidental GSI, the incidence proportion per 100k between 2017 and 2023 increased from 8.81 to 21.11 (Relative Risk: 2.397, 95% CI: 2.076, 2.768, P < 0.001). CONCLUSION: The study supports the shift in the leading cause of death among children from motor vehicle accidents to GSIs, with the continued rise in rates despite the coronavirus disease 2019 pandemic. Accidental injuries constituted the majority of GSIs, indicating the need for enhanced gun safety measures, including requirements for gun storage, keeping firearms locked and unloaded, requiring child supervision in homes with guns, and enforcing stricter punishments as penalties. Comprehensive efforts are required to address this public health crisis. Pediatricians play a vital role in counseling and educating families on firearm safety. LEVEL OF EVIDENCE: Level III.

Flexor Pollicis Longus Reconstruction After Rupture Following Distal Radius Fixation With Volar Locking Plate: A Technique Guide.

Flexor pollicis longus rupture is an uncommon but potentially debilitating complication after volar locking plate fixation of distal radius fractures, occurring secondary to tendon attrition against the implant. This nature of tendon injury typically precludes primary repair. This paper will illustrate 2 reconstruction techniques, an interpositional tendon graft and a tendon transfer, that have been utilized successfully by the authors.

Distal Radius Salter-Harris II Fracture Loss of Reduction: The Importance of Coronal Plane Angulation in Older Children.

OBJECTIVES: To assess factors affecting the loss of reduction (LOR) in a large cohort of children with Salter-Harris Type II (SH II) distal radius physeal fractures treated with closed reduction. DESIGN: Retrospective chart review. SETTING: Pediatric Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 141 pediatric patients (73% male, average age: 12.15 ± 2.55 years) that had undergone closed reduction and casting for distal radius physeal fractures from 2006 to 2019 were included in this study. INTERVENTION: Closed reduction and casting. MAIN OUTCOME MEASUREMENTS: Five different radiographic measurements were analyzed at 4 different time points. Follow-up radiographs were assessed in relation to initial reduction. LOR was defined as >5 degrees change of angulation on PA radiographs, >10 degrees change of angulation on lateral radiographs, and/or >25% translation on PA or lateral radiographs. RESULTS: LOR was seen in 28.4% of the patients, most often (68%) in the first 2 weeks after initial reduction. Seven (17.5%) of these patients (average age: 15.2 ± 2.0 years) were treated surgically with closed reduction and percutaneous pinning (CRPP). Patients undergoing CRPP for LOR were an average of 3.4 years older ( P < 0.001) than those who underwent nonoperative treatment of LOR. Patients with initial angulation more than 5 degrees on the PA view to be twice as likely to have LOR ( P = 0.03). CONCLUSIONS: LOR was seen in nearly 1/3 of these patients. Patients with initial higher degree of angulation on the coronal plane are at higher risk for LOR. Age, not the degree of angulation, is the main predictor for potential surgical treatment. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Striving for Inclusive Excellence in the Recruitment of Diverse Surgical Residents During COVID-19.

The COVID-19 pandemic has dramatically altered the 2020 residency application cycle and resulted in many changes to the usual application processes. Particular attention should be placed on the obstacles faced by applicants who are underrepresented in medicine (URiM) as they may be disproportionately affected by the changes in 2020. These challenges are especially relevant in competitive surgical specialties, where racial and gender diversity already lags behind other medical specialties. Inclusive excellence is a guiding philosophy in creating equitable resident selection processes. It focuses on the multilayered processes that form the foundation of inclusive institutional culture, while recognizing that excellence and inclusivity are mutually reinforcing and not mutually exclusive. A key tenant in inclusive excellence for resident recruiting involves applying an equity lens in all decision making. An equity lens allows programs to continuously evaluate resident selection policies and processes through an intentional equity-forward approach. In addition to using an equity lens, programs should emphasize the importance of equity-focused skill building, which ensures that all individuals engaged in the resident selection process have the tools and knowledge to recognize biases. Finally, institutions should implement specific programming for URiM applicants to provide them with information about key aspects of department culture and mechanisms of support for URiM trainees. Every residency program should adopt a sustained perspective of inclusive excellence, in this application cycle and beyond. The status quo has existed for far too long, and COVID-19 offers institutions and their residency programs a unique opportunity to try new and innovative equity-forward practices.

A Novel MRI Tool for Evaluating Cortical Bone Thickness of the Proximal Femur.

BACKGROUND: Osteoporotic hip fractures heavily cost the health care system. Clinicians and patients can benefit from improved tools to assess bone health. Herein, we aim to develop a three-dimensional magnetic resonance imaging (MRI) method to assess cortical bone thickness and assess the ability of the method to detect regional changes in the proximal femur. METHODS: Eighty-nine patients underwent hip magnetic resonance imaging. FireVoxel and 3DSlicer were used to generate three-dimensional proximal femur models. ParaView was used to define five regions: head, neck, greater trochanter, intertrochanteric region, and subtrochanteric region. Custom software was used to calculate the cortical bone thickness and generate a color map of the proximal femur. Mean cortical thickness values for each region were calculated. Statistical t-tests were performed to evaluate differences in cortical thickness based on proximal femur region. Measurement reliability was evaluated using coefficient of variation, intraclass correlation coefficients, and overlap metrics. RESULTS: Three-dimensional regional cortical thickness maps for all subjects were generated. The subtrochanteric region was found to have the thickest cortical bone and the femoral head had the thinnest cortical bone. There were statistically significant differences between regions (p < 0.01) for all possible comparisons. CONCLUSIONS: Cortical bone is an important contributor to bone strength, and its thinning results in increased hip fracture risk. We describe the development and measurement reproducibility of an MRI tool permitting assessment of proximal femur cortical thickness. This study represents an important step toward longitudinal clinical trials interested in monitoring the effectiveness of drug therapy on proximal femur cortical thickness.

Segmentation of the Proximal Femur from MR Images using Deep Convolutional Neural Networks.

Magnetic resonance imaging (MRI) has been proposed as a complimentary method to measure bone quality and assess fracture risk. However, manual segmentation of MR images of bone is time-consuming, limiting the use of MRI measurements in the clinical practice. The purpose of this paper is to present an automatic proximal femur segmentation method that is based on deep convolutional neural networks (CNNs). This study had institutional review board approval and written informed consent was obtained from all subjects. A dataset of volumetric structural MR images of the proximal femur from 86 subjects were manually-segmented by an expert. We performed experiments by training two different CNN architectures with multiple number of initial feature maps, layers and dilation rates, and tested their segmentation performance against the gold standard of manual segmentations using four-fold cross-validation. Automatic segmentation of the proximal femur using CNNs achieved a high dice similarity score of 0.95 ± 0.02 with precision = 0.95 ± 0.02, and recall = 0.95 ± 0.03. The high segmentation accuracy provided by CNNs has the potential to help bring the use of structural MRI measurements of bone quality into clinical practice for management of osteoporosis.

3-T MR Imaging of Proximal Femur Microarchitecture in Subjects with and without Fragility Fracture and Nonosteoporotic Proximal Femur Bone Mineral Density.

Purpose To determine if 3-T magnetic resonance (MR) imaging of proximal femur microarchitecture can allow discrimination of subjects with and without fragility fracture who do not have osteoporotic proximal femur bone mineral density (BMD). Materials and Methods Sixty postmenopausal women (30 with and 30 without fragility fracture) who had BMD T scores of greater than -2.5 in the hip were recruited. All subjects underwent dual-energy x-ray absorptiometry to assess BMD and 3-T MR imaging of the same hip to assess bone microarchitecture. World Health Organization Fracture Risk Assessment Tool (FRAX) scores were also computed. We used the Mann-Whitney test, receiver operating characteristics analyses, and Spearman correlation estimates to assess differences between groups, discriminatory ability with parameters, and correlations among BMD, microarchitecture, and FRAX scores. Results Patients with versus without fracture showed a lower trabecular plate-to-rod ratio (median, 2.41 vs 4.53, respectively), lower trabecular plate width (0.556 mm vs 0.630 mm, respectively), and lower trabecular thickness (0.114 mm vs 0.126 mm) within the femoral neck, and higher trabecular rod disruption (43.5 vs 19.0, respectively), higher trabecular separation (0.378 mm vs 0.323 mm, respectively), and lower trabecular number (0.158 vs 0.192, respectively), lower trabecular connectivity (0.015 vs 0.027, respectively) and lower trabecular plate-to-rod ratio (6.38 vs 8.09, respectively) in the greater trochanter (P < .05 for all). Trabecular plate-to-rod ratio, plate width, and thickness within the femoral neck (areas under the curve [AUCs], 0.654-0.683) and trabecular rod disruption, number, connectivity, plate-to-rod ratio, and separation within the greater trochanter (AUCs, 0.662-0.694) allowed discrimination of patients with fracture from control subjects. Femoral neck, total hip, and spine BMD did not differ between and did not allow discrimination between groups. FRAX scores including and not including BMD allowed discrimination between groups (AUCs, 0.681-0.773). Two-factor models (one MR imaging microarchitectural parameter plus a FRAX score without BMD) allowed discrimination between groups (AUCs, 0.702-0.806). There were no linear correlations between BMD and microarchitectural parameters (Spearman ρ, -0.198 to 0.196). Conclusion 3-T MR imaging of proximal femur microarchitecture allows discrimination between subjects with and without fragility fracture who have BMD T scores of greater than -2.5 and may provide different information about bone quality than that provided by dual-energy x-ray absorptiometry. © RSNA, 2018.