The epidemiology of nonaccidental trauma in children.

BACKGROUND: Abuse of children is abhorrent in Western society and, yet, is not uncommon. Nonaccidental trauma (NAT) is the result of a complex sociopathology. Not all of the causative factors of NAT are known, many are incompletely described, not all function in each case, and many are secondary to preexisting pathology in other areas. QUESTIONS/PURPOSES: We therefore addressed the following questions in this review: (1) what is the general incidence of NAT; (2) what factors are intrinsic to the abused child, family, and society; and (3) what orthopaedic injuries are common in NAT? METHODS: We searched Medline, Medline In Process & Other Non-Indexed Citations, and Embase using OVID. Only one article fit our inclusion criteria; therefore, this is a descriptive generalized review of the epidemiology of NAT. RESULTS: The general incidence of NAT ranges from 0.47 per 100,000 to 2000 per 100,000. Younger children are at greater risk of NAT than older children. Parents are often the perpetrators of the abuse. Rib fractures are highly indicative of NAT in young children. CONCLUSIONS: It is important to consider child, family, and societal factors when confronted with suspicions of child abuse. Our review demonstrates the currently limited information on the true incidence of NAT. To determine a much more accurate incidence of NAT, there needs to be a population-based surveillance program conducted through primary care providers.

The effect of surgical timing on operative duration and quality of reduction in Type III supracondylar humeral fractures in children.

PURPOSE: To determine the influence of the time from injury to surgery of Type III supracondylar fractures on operative duration and quality of reduction. METHODS: A retrospective review of Type III supracondylar fractures treated by closed reduction and percutaneous pinning over a 3-year period was performed. RESULTS: The subjects were divided into two groups based on the time from injury to surgery (IST): Group 1 (<8 h) 48 subjects and Group 2 (>8 h) 39 subjects. There was no difference in the mean age or gender ratio between the two groups. There were no cases of compartment syndrome or conversion to open reduction in either group. The mean IST was 669 min. The mean IST for Group 1 was 340 min and it was 1,074 min for Group 2. The operative duration for Group 1 was 32.56 min and for Group 2 it was 31.72 min (P = 0.77). There were no significant differences in the quality of reduction. CONCLUSIONS: There was no difference in the operative duration demonstrated between IST <8 h and IST >8 h. This failure to demonstrate a difference should not be interpreted as demonstrating equivalence. This study does not conclude that all displaced supracondylar fractures should be delayed, though it does inform the surgeon that, if compelled to delay surgery, this series did not demonstrate an increased risk of complications, nor a worsened quality of reduction.

Inter-observer and intra-observer agreement in the radiographic diagnosis of avascular necrosis of the femoral head following slipped capital femoral epiphysis.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder. Avascular necrosis (AVN) of the femoral head is a devastating complication of SCFE. The frequency of this complication reported in the literature has been variable. It was the objective of this study to estimate the inter- and intra-observer agreement between two experienced pediatric orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE. METHODS: A retrospective review of all cases of SCFE treated at our center between 1995 and 2005 was performed. All cases of AVN and a random sample of 19 of the remaining cases were selected for study. The most recent anteroposterior and lateral radiographs were presented to two experienced pediatric orthopaedic surgeons in a random order. Inter-observer reliability was determined by calculating the kappa statistic to assess for clinical agreement. Each observer repeated this process two weeks after the initial review. RESULTS: There were a total of 103 cases of SCFE, of which four were diagnosed with AVN. The inter-observer agreement in the first trial was 0.79. The intra-observer agreement for the first observer was 0.9 and for the second observer, it was 0.88. CONCLUSION: The agreement, both inter- and intra-observer, for the radiographic diagnosis of AVN amongst adolescents with previous SCFE is very high. The results of this study suggest that the reported discrepancy of AVN in the literature following SCFE is not likely due to the lack of inter- and intra-observer agreement.

Outcome analysis of chance fractures of the skeletally immature spine.

STUDY DESIGN: Observational. OBJECTIVE: The authors present a detailed description of 25 skeletally immature patients with Chance fractures with a mean follow-up of 6.4 years. SUMMARY OF BACKGROUND DATA: Since the legislation mandating seat belt usage in Canada was first introduced, the fatality rate of automobile collisions has decreased significantly. However, seat belts do not result in the complete elimination of injury. Fractures of the lumbar spine due to seat belts are well recognized in adolescents and adults but there are few reports in young children. METHODS: Radiographic images and patient records were analyzed for information on patient demographics and injury details. RESULTS: Treatment involved either posterior instrumentation (n = 16) or a conservative approach using casting or bracing (n = 9). Concomitant injuries were documented. A deformity index was developed as a simple value to take into account the severity of both anterior loss of vertebral height and posterior distraction. CONCLUSION: The deformity index was significantly higher in patients with a concomitants abdominal injury and significantly higher in patients managed operatively. Functional outcome scores were completed on 14 of the patients. Patients scored within the reported norms on the SF-36 version 2 but scored poorly on the pain and disability component of the AAOS lumbar specific questionnaire. These outcomes indicate a need for using an injury specific score to accurately quantify disability.

A clinicoradiologic study of the shoulder in Apert syndrome.

UNLABELLED: To provide a comprehensive radiographic, clinical, and functional description of the shoulder in Apert syndrome. METHODS: A cohort of 9 Apert syndrome patients (ages, 9-27 years) followed at a tertiary care facility was included in this prospective study. Patients were clinically assessed with physical examination and completion of 2 validated functional assessment tools, the Shoulder Pain and Disability Index (SPADI) and American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (AAOS PODCI). Radiographs were obtained of both shoulders, and standardized-protocol magnetic resonance imaging was performed on the dominant shoulder of all participants. RESULTS: All patients had some degree of functional impairment attributable to their shoulder pathologic abnormality. Physical examination consistently revealed reduced forward flexion and abduction. Radiographic findings were similar to previous reports, with pervasive osseous dysplasia of the shoulder joint. Medial humeral head hypoplasia was seen in 8 of 9 patients and greater tuberosity overgrowth in 7 of 9 patients. Magnetic resonance imaging of the shoulder, not previously performed in a cohort of Apert patients, allowed better delineation of abnormalities seen radiographically such as a central glenoid cleft seen in 8 of 9 patients. It also revealed a new finding of inferior glenoid inclination (7/9 patients) that has not been described in the literature. Very few soft tissue or degenerative abnormalities were demonstrated. CONCLUSIONS: The findings of this study confirm that patients with Apert syndrome are functionally impaired by their shoulder pathologic abnormality, which may have a similar clinical impact as the more well-described hand and foot anomalies. The global functioning of patients with Apert syndrome is equivalent to patients with juvenile rheumatoid arthritis. The shoulder range of motion in Apert patients is decreased, most significantly in flexion and abduction. Radiographs confirmed previous imaging findings of glenohumeral dysplasia. The novel magnetic resonance imaging component demonstrated consistent inferior glenoid inclination, which may be a significant factor in their shoulder impairment. Magnetic resonance imaging revealed no significant soft tissue or degenerative abnormalities to account for their clinical disability. These findings have potential relevance in the surgical and clinical management of these patients. LEVEL OF EVIDENCE: Level IV.

The mutant guppy syndrome curveback as a model for human heritable spinal curvature.

STUDY DESIGN: This study investigated the morphology, pathogenesis, and inheritance of idiopathic-like spinal curvature in the guppy syndrome, curveback. OBJECTIVE: To determine whether curveback could be applied as a model for the primary factors that contribute to heritable spinal curvature in humans, specifically, the etiopathogenesis of human familial idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Although a genetic basis is accepted, phenotypic complexity and the lack of an animal model with noninduced curvature have made identification of idiopathic scoliosis etiology difficult. It is well established that humans and fish share many genes with similar tissue and temporal expression characteristics, and comparisons between human and fish genomes have proven to be valuable for understanding the genetics of diseases affecting humans. METHODS: The curveback lineage of guppies was constructed from a single curved male crossed to a normal female. Offspring (103) from the original cross were scored from birth until death for the presence and magnitude of spinal curvature. Genetic architecture was investigated through selective inbreeding, analysis of the distribution of curve magnitude in the mature population, and assessment of curve dynamics during development. Computed tomography assessed vertebral detail. RESULTS: Computed tomography reveals that vertebral breakage or fusion is not associated with the curveback syndrome. Inbreeding demonstrates a strong genetic influence on curveback, and the distribution of curve magnitude among adult fish suggests polygenic inheritance. There is a female bias for curves of high magnitude and curves that resolve before maturity. There is developmental variability for the age of curve onset, curve progression, and final curve magnitude. CONCLUSIONS: Observed parallels between the curveback syndrome and human idiopathic scoliosis suggest that the guppy model is an unexploited resource for the identification of primary etiological factors involved in curvature. As models for biomedical research, teleosts offer great potential regarding spinal stability and deformity.

Abdominal aortic injuries associated with chance fractures in pediatric patients.

Injury to the abdominal aortic artery from blunt trauma is an infrequent event with few cases reported in either the adult or the pediatric literature. Injury to the thoracic aorta after blunt abdominal trauma is more common. It has been estimated that 95% to 99% of all aortic disruptions are in the thoracic region. Injury to the abdominal aorta is rarely seen in association with fractures of the lumbar spine secondary to seat belt use in motor vehicle accidents; there are few cases in the literature of these injuries in pediatric patients. Nevertheless, the overall mortality rate of this injury has been reported to be between 18% and 37%. It is therefore important to be aware of the possible association to allow prompt diagnosis and management of multitraumatized patients because extensive injuries to the abdominal viscera may mask aortic dissection and prognosis is significantly improved with early intervention.

The effect of interbody cage positioning on lumbosacral vertebral endplate failure in compression.

STUDY DESIGN: A biomechanical investigation using a human cadaver, multisegmental lumbosacral spine model. OBJECTIVES: To determine if 2 small, posterolaterally positioned titanium mesh interbody cages would provide superior construct strength and stiffness in compression compared to central cage placement. In addition, determine construct stiffness with interbody cages as opposed to an intact spine and assess the effect of bone mineral density (BMD). SUMMARY OF BACKGROUND DATA: Previous work has shown that the posterolateral corners of the lumbosacral endplates are stronger than the anterior and central regions. Information to suggest appropriate interbody cage positioning to avoid subsidence into adjacent vertebrae would be valuable for spine surgeons and implant designers. METHODS: A total of 27 functional spinal units from L3 to S1 were dual x-ray absorptiometry scanned for BMD, instrumented with pedicle screw systems, and tested to failure in compression with titanium mesh interbody cages placed in 1 of 3 positions: 2 small posterolateral, 2 small central, or 1 large central. Analysis of covariance was conducted to compare failure load and stiffness across the different cage configurations. Repeated measures analysis of variance was used to analyze stiffness between functional spinal units with intact disc, discectomy, or interbody cages. Failure load was correlated against BMD. RESULTS: Of the 3 placement patterns, 2 small titanium mesh cages in the posterolateral corners had 20% higher failure loads, although the difference was not significant (P = 0.20). Stiffness in compression for the 3 cage positions was not significantly different (P = 0.82). All intact discs with posterior instrumentation were significantly stiffer than any of the cage patterns (P = 0.0001). BMD of the vertebrae significantly correlated with failure loads (P = 0.007). CONCLUSIONS: The placement of 2 small interbody cages posterolaterally tended to result in higher failure loads than central cage placement, although the results were not statistically significant. It is noteworthy that cage placement in any position resulted in a less stiff construct in compression than with an intact disc.

Clinical usefulness of somatosensory evoked potentials for detection of brachial plexopathy secondary to malpositioning in scoliosis surgery.

STUDY DESIGN: A retrospective longitudinal study of 434 consecutive pediatric patients who underwent surgical correction of scoliosis, while being monitored for positional brachial plexopathy. OBJECTIVE: To evaluate the effectiveness of intermittent monitoring of ulnar nerve somatosensory evoked potentials (SSEPs) for detecting brachial plexus injury caused by malpositioning during scoliosis surgery. SUMMARY OF BACKGROUND DATA: Continuous intraoperative SSEP monitoring for spinal cord function has been well reported, and is widely accepted as the standard for spinal deformity correction surgery to detect and avoid neurologic injury. The use of SSEPs for the monitoring of ulnar nerve function intraoperatively as an indicator of brachial plexus function is becoming more accepted as a valid and useful technique to minimize intraoperative neurologic injuries during deformity corrections. METHODS: A review was conducted to assess the effect of ulnar nerve SSEP monitoring, as a measure of brachial plexus function, during anterior, posterior, or combined approach surgeries. The type of scoliosis, type of surgery and positioning, and surgical event at noted amplitude decrease were included in an analysis of variance for repeated measures, and a Student t test was performed for significant differences. RESULTS: A total of 27 patients had ulnar nerve amplitude decreases of > or =30%, resulting in a point prevalence of 6.2% for positional brachial plexopathy during positioning for all scoliosis surgeries. A significant difference was noted between the types of positioning, with prone positioning accounting for a higher rate of brachial plexopathy compared with anterior approach positioning (P < 0.01). No statistical difference exists as to the type of scoliosis present and the incidence of brachial plexopathy (P < 0.01). CONCLUSIONS: Avoidance of neurologic injury to the brachial plexus during scoliosis surgery is possible by early detection with ulnar nerve SSEP monitoring.

Sternal split approach to the cervicothoracic junction in children.

STUDY DESIGN: We present a descriptive case series outlining the surgical technique and outcome in six patients managed with a combined anterior neck and sternal splitting approach. OBJECTIVES: To describe a surgical approach used in the management of severe cervicothoracic kyphosis and/or scoliosis in pediatric patients. SUMMARY OF BACKGROUND DATA: There are few reports in the literature that address the problem of accessing multileveled spinal deformities around the cervicothoracic junction requiring stabilization in the pediatric population. METHODS: A detailed chart and radiographic review was completed of six consecutive patients managed at our center with a combined anterior neck and sternal splitting approach. The indications, surgical technique, and outcome are reviewed for each case. This technique was employed in 6 pediatric patients, aged 3-15 years, at the authors' institution. Diagnoses included Klippel-Feil Syndrome (2 patients), Proteus Syndrome, Larsen Syndrome, and neurofibromatosis type I (2 patients). All patients had severe cervicothoracic kyphosis requiring surgical instrumentation. This technique allowed surgical access from C5-T6. RESULTS: This approach was invaluable in gaining access to the cervicothoracic junction to address complex spinal deformities in pediatric patients. In one patient, a separate thoracotomy was performed to access the lower thoracic spine. The only significant complication related to the approach was recurrent laryngeal nerve palsy experienced by one patient. This approach allowed stabilization of severe scoliotic and/or kyphotic deformities to impede curve progression. CONCLUSIONS: This approach was invaluable in gaining multileveled access to the cervicothoracic junction to address complex spinal deformities in pediatric patients.

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes.

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

Vertebral scalloping in neurofibromatosis type 1: a quantitative approach.

OBJECTIVE: To investigate quantitative differences in vertebral scalloping between children who have scoliosis with and without neurofibromatosis type 1 (NF1). DESIGN: A retrospective study. SETTING: A university-affiliated children's hospital. PATIENTS: Twenty-seven children with scoliosis, 13 of whom had NF1 and 14 of whom did not. METHOD: Existing radiographs of the lumbar vertebrae were used to measure and compare the degree of vertebral scalloping. MAIN OUTCOME MEASURES: The distribution of posterior scalloping ratios in the 2 groups and the most extreme ratio in each subject in each group were compared. RESULTS: Scalloping ratios from the children with NF1 were not normally distributed: 31% had ratios greater than 1.20. Scalloping ratios from the non-NF1 children were normally distributed, with a mean ratio (and standard deviation) of 1.13 (0.03). The distribution between the 2 groups was significantly different (p < 0.05). CONCLUSIONS: In children who have scoliosis but no NF1 there was a range of mild scalloping whereas those with NF1 has severe scalloping. Further studies are needed to determine the possible role of vertebral scalloping in scoliosis severity and progression in children who have NF1.

Intra-Operative Analysis of Scoliosis Surgery in 3-D.

Scoliosis is a three-dimensional deformity characterized by coronal, sagittal and axial rotation of the spine. Surgical fusion of the spine is required in severe cases. Assessment of the surgical procedure requires enough accuracy and flexibility to allow planning of individual interventions or implant designs. Conventional 2-D radiography and even 3-D CT scanning have limitations for in-depth analysis of scoliosis that limit the ability to see the three-dimensional deformity and expose the patient to considerable doses of radiation, respectively. Our stereophotogrammetric analysis is able to provide accurate, intra-operative measurement of vertebral movement during surgical manuevres. Stereophoto pairs taken at each stage of the operation and robust statistical techniques can be used to determine rotation, translation, goodness of fit, and overall spinal contour before, during, and after the surgical instrumentation. A demonstration of data available from this system is included.