Controversies in the Management of Pediatric Musculoskeletal Infections: An International Viewpoint.

Pediatric musculoskeletal infections (MSIs) are a major contributor to the global burden of musculoskeletal disease in children and young adults. If untreated, or treated inappropriately or inadequately, pediatric bone and joint infections can be fatal or result in morbidity that causes significant functional disabilities to the patient and economic burden to the family and the community at large. The past decade has witnessed many advances in this field with respect to early diagnosis, management, and prevention of complications. It is important to discuss the current controversies in the management of pediatric MSIs with an international perspective. This discussion should include the controversies associated with the early diagnosis and identification of pediatric MSI in diverse settings; the controversies involved in the nonsurgical and surgical management of acute pediatric MSIs; and the controversies associated with the management of sequelae of pediatric MSI.

Primary Fibular Osteomyelitis in Children: A Systematic Review.

Osteomyelitis of the fibula is rare and is especially rare in children. The published literature is limited to case series and is thus lacking a comprehensive description of the disease. The purpose of this systematic review is to provide the first comprehensive summary of the demographics, presenting symptoms, laboratory values, microbiology, and treatment results of osteomyelitis of the fibula in children based on the existing literature. This institutional review board (IRB)-exempt systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. Three search engines were used for a total of 239 studies. Twenty-six studies were screened by full text. Twelve articles underwent a quantitative analysis. Due to limited data and heterogenous reporting, the data were summarized descriptively. The methodologic quality of the studies was evaluated based on the Newcastle-Ottawa scale. The average age was 7.71±3.49 years, and males comprised 57% of the 21 cases. The most common presenting symptoms were fever (86%), antalgic gait (57%), and localized tenderness (81%). The most common site of involvement was the distal third of the fibula (90%). The average C-reactive protein (CRP) was 90.1±38.3 mg/L, and the average erythrocyte sedimentation rate (ESR) was 58.8±21.2 mm/hour. Staphylococcus aureus was the most cultured pathogen reported in 10/21 cases (48%). Open surgery was performed in 17/21 cases (81%), and there were no reported complications. Fever, antalgic gait, and localized tenderness should raise the index of suspicion. Prompt laboratory and radiographic evaluations can help reduce delays in diagnosis and improve outcomes. Blood and tissue cultures are currently performed in about half of the cases. Improvement in our microbiologic diagnosis has the potential to improve antibiotic selection. Local methicillin-resistant Staphylococcus aureus (MRSA) prevalence must be taken into consideration when starting empiric antibiotic treatment. Surgical treatment is often required with a low complication rate. The clinical and laboratory parameters identified in this study have the potential for integration into a composite clinical score.

Fungal Osteomyelitis of the Proximal Tibial Epiphysis and Septic Arthritis Secondary to an Open Wound: A Case Report.

CASE: A 9-year-old boy presented with a painful, swollen knee. He had a wound on the knee 2 months ago after a fall in contaminated water. At another hospital, this was treated with debridement twice, and the patient received several antibiotics. Imaging showed septic arthritis and epiphyseal osteomyelitis involving the proximal medial tibia. Surgical debridement and joint washout were performed. Fungal cultures grew Scedosporium boydii. Antifungal treatment with voriconazole was given. At a 5-year follow-up, we noticed favorable outcomes without any complications. CONCLUSIONS: Fungal osteomyelitis because of direct inoculation should be considered a rare differential diagnosis while treating epiphyseal osteomyelitis.

Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature.

Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.

Acute Isolated Irreducible Proximal Interphalangeal Joint Dislocation of the Fifth Toe in a Toddler: A Case Report.

A male child aged three years and three months presented after stubbing his right fifth toe. Imaging revealed a dorsolateral dislocation of the proximal interphalangeal joint (PIPJ). After failed attempts at closed reduction, open reduction and internal fixation was pursued. At the one-year follow-up, the patient was found to be doing well clinically and radiographically. These types of injuries require a high degree of clinical suspicion to obtain the proper imaging. The interposition of adjacent soft tissues can render these injuries irreducible. When irreducible, open reduction and pin fixation may be appropriate after an adequate trial of closed reduction under anesthesia. Concomitant ligamentous injuries, avulsion injuries, and fracture-dislocations often accompany these injuries; however, they can also occur in isolation.

Progressive Ankle Subluxation Following Panfibular Osteomyelitis Requiring Fibular Resection.

A 10-month-old boy presented with fever, a swollen left leg, and septicemic shock. He was diagnosed with panfibular osteomyelitis. Failure of combined medical and surgical treatment to achieve source control necessitated fibular resection. He subsequently developed a progressive superolateral subluxation of his left ankle, valgus deformity, and brace intolerance. Tibiotalar arthrodesis resulted in a stable plantigrade ankle, excellent weight-bearing ability, and a minor leg-length discrepancy at the 14-month postoperative follow-up.

Lower Limb Alignment in Indian Children: A Radiographic Analysis of Coronal Plane Parameters.

Objectives: Indian children are known to have variations in the tibiofemoral angle as compared to children of other ethnicities. There is no study describing radiographic angles in coronal plane in Indian children. Our aim was to evaluate coronal plane alignment in Indian children. Methods: Database of radiographs between January 2011 and December 2019 was searched. Full-length standing radiographs of patients younger than 16 years with unilateral congenital or post-traumatic or post-infective deformity were included. The radiographs were measured for mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), tibiofemoral angle (TFA), hip-knee-ankle (HKA) angle, lateral distal tibial angle, mechanical axis deviation (MAD), and mechanical lateral proximal femoral angle. Results: Analysis of 221 lower limbs of 177 children is presented. There were 103 (58.2%) boys and 74 (41.8%) girls. Mean age was 8 years, 6 months (range: 2 years, 1 month to 15 years, 11 months). The mean mLDFA remained constant between 87° and 88° after the age of 5 years. The mean MPTA remained around 88° after 8 years of age. The mean MAD remained within 4 mm of the midpoint of the knee after the age of 8 years. The adult value of TFA was achieved after 8 years of age. The mLDFA, MPTA, and mLPFA are significant predictors of change in the TFA. Conclusion: The development of tibiofemoral angle in Indian children is slightly different than children of other ethnicities. We recommend using age-specific values for Indian children younger than 8 years of age.

Primary Bacterial Pyomyositis in Children: A Systematic Review.

BACKGROUND: Tropical pyomyositis has had a recent increase in the United States, Europe, and other nontropical areas. The purpose of this study was to provide an accurate description of the demographics, presenting features, sites of involvement, microbiology, imaging modalities, medical and surgical management, complications, and predictors of clinical course. METHODS: We searched PubMed, Cochrane, Web of Science Collection, Scopus, and Embase databases yielding 156 studies. Of these, 23 articles were selected for statistical analysis. RESULTS: The average age at presentation was 8.4±1.9 years with males more commonly affected. Fever, painful limp, and localized pain were the most common presenting symptoms. Pelvis, lower extremity, trunk and spine, in descending order, were the most commonly affected locations. Iliopsoas, obturator musculature, and gluteus musculature were the most commonly affected muscle groups. The mean time to diagnosis was 6.6±3.05 days. Staphylococcus aureus was the most common offending organism. The mean length of hospital stay was 12.0±4.6 days. Medical management alone was successful in 40% of cases (143/361) with an average duration of 9.5±4.0 and 22.7±7.2 days of intravenous and oral antibiotics, respectively. Surgical management consisted of open drainage in 91.3% (199/218) or percutaneous drainage in 8.7% (19/218) of cases. Painful limp, fever, and larger values of white cell count and erythrocyte sedimentation rate were associated with an increased need for surgery. Obturator and calf muscle involvement were strongly associated with multifocal involvement. There were 42 complications in 41 patients (11.3%). Methicillin-resistant S. aureus was associated with an increased risk of complications. The most common complications were osteomyelitis, septicemia, and septic arthritis. CONCLUSIONS: Primary pyomyositis should be considered in cases suggesting pediatric infection. Magnetic resonance imaging is the most commonly used imaging modality; however, ultrasound is useful given its accessibility and low cost. Medical management alone can be successful, but surgical treatment is often needed. The prognosis is favorable. Early diagnosis, appropriate medical management, and potential surgical drainage are required for effective treatment. LEVEL OF EVIDENCE: Level IV-systematic review.

Tension-Sided Femoral Neck Stress Fracture in an Adolescent with Vitamin D Deficiency and Osteomalacia: A Case Report.

CASE: An adolescent girl presented with groin pain without any history of trauma. Imaging showed a tension-sided stress fracture of the femoral neck. Vitamin D deficiency (VDD), and raised alkaline phosphatase and parathyroid hormone levels were found. Pain relief was not achieved with nonoperative treatment. Considering the risk of fracture progression and displacement, the fracture was fixed with cannulated cancellous screws. Fracture healed without any complications. CONCLUSION: A tension-sided femoral neck stress fracture, with VDD and osteomalacia, is a rare cause of hip pain in an adolescent. Surgical fracture stabilization is necessary in addition to medical treatment.

Intraoperative Kirschner Wire Breakage in a Pediatric Supracondylar Humerus Fracture.

A displaced supracondylar humerus in a child is usually treated with closed reduction and percutaneous Kirschner (K)-wire fixation. The procedure is straightforward and usually yields excellent outcomes. In general, intraoperative complications are uncommon and intraoperative complications related to K-wires are exceedingly rare. We present the case of intraoperative K-wire breakage while performing closed reduction and K-wire fixation for a pediatric supracondylar humerus fracture. This unusual complication occurred while drilling through the medial cortex and the broken end of the K-wire disappeared under the skin in the cartilaginous distal humerus. The broken wire was removed by making an incision over the broken end. This report serves as a reminder to follow principles of drilling and avoid K-wire-related complications while performing percutaneous fixation of the pediatric supracondylar humerus fracture.

Prospective Study of Gross Motor Milestones in Children with Severe Idiopathic Clubfoot Treated by Ponseti Method.

BACKGROUND: A prospective study of motor milestones achieved in severe clubfeet treated by Ponseti method and comparison between unilateral and bilateral clubfoot will help us gain further insight of motor milestones in these children. METHODS: Prospective study of 150 consecutive children with idiopathic clubfoot who were treated by Ponseti method and in whom percutaneous tendoachilles tenotomy was performed. The gross motor milestones recorded were: rolls from back to stomach, sitting without support, standing with assistance, walks with assistance, standing alone, walking alone. This was compared with published regional and World Health Organization (WHO) normal data. RESULT: 15 patients were excluded due to non-compliance and recurrence. Children with unilateral clubfoot (80 children) and bilateral clubfoot (55 children) showed a delay of 0.2-2.1 months in various milestones, and this was statistically significant when compared with both normal data. 95% children with unilateral clubfoot had independent ambulation by 17 months and in bilateral ambulation by 17.8 months. There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support. CONCLUSION: There is a delay in achievement in all children with clubfoot, with more delay in bilateral clubfoot as compared to unilateral clubfoot. The probable reasons could be plaster treatment, possible weakness due to tendoachilles tenotomy, use of orthosis or the inherent pathology associated with clubfeet. Parents hence need to be explained about this delay.

A Novel Technique for the Removal of Elastic Intramedullary Nail in Pediatric Long Bones: A Technical Note.

Elastic stable intramedullary nails have been commonly used to treat unstable long bone fractures in children. The nail tip at the insertion site can cause problems. The nail tip should be of optimal length as a prominent nail tip or a short nail tip, or both, may cause different sets of problems. If the nail tip is short, nail removal after fracture union can be difficult and may pose challenges. A short nail tip may lead to difficulty in nail removal, longer duration of surgery, and need for special equipment for extracting the nail. Few techniques have been suggested in the past for removing elastic nail with the short tip, but all these techniques need special instruments. We describe a surgical technique using a metallic suction cannula to aid elastic nail removal. This method utilizes an easily available instrument in the operating room and does not need any special equipment.

Radiation Safety Knowledge and Practices: Is the Indian Orthopaedic Community Well-informed?

BACKGROUND: In spite of frequent exposure to radiation, orthopaedic surgeons lack knowledge about radiation safety and do not comply with safety practices. We surveyed orthopaedic trainees and consultants in India to determine their knowledge and practices regarding radiation safety. METHODS: A questionnaire with 16 multiple choice questions was sent out using Google forms. We included practicing orthopaedic surgeons (consultants), fellows and trainees pursuing DNB, MS and D. Ortho courses across India. RESULTS: We received 439/700 responses (62.7% response rate) from 233 (53.1%) consultants and 206 (46.9%) trainees. Only 71 (16.2%) were aware of the ALARA (As Low As Reasonably Achievable) principle. While lead aprons were always used by 379 (86.3%), thyroid shields were never used by 302 (68.8%) respondents. Knowledge about the ALARA principle was significantly associated with radiation safety practices. A significantly greater proportion of participants who were aware about the ALARA principle always used lead aprons (OR 1.15; 95% CI 1.0 to 1.2, p = 0.001) and thyroid shields (OR 2.00; 95% CI 1.0 to 3.7, p = 0.029) and had their dosimeters checked within the last 1 year (OR 1.69; 95% CI 1.0 to 2.8, p = 0.039) when compared to those who were not aware of the ALARA principle. Almost 99% respondents expressed interest in participating in a radiation safety training program. CONCLUSION: A majority of the respondents were keen to obtain training in radiation safety. We believe that professional organizations and hospitals could initiate training programs for the orthopaedic community in India to improve their radiation safety knowledge and practices.

YouTube as an information source for clubfoot: a quality analysis of video content.

Idiopathic clubfoot is the most common congenital anomaly of the lower extremity. YouTube has emerged as an important source of health-related information for patients and families. Parents seek information about clubfoot on YouTube. However, the quality of these videos remains unknown. Therefore, we decided to evaluate the quality of YouTube videos about clubfoot. We searched YouTube for clubfoot videos using appropriate keywords. English language videos with more than 10 000 views were included. Three fellowship trained pediatric orthopedic surgeons independently assessed the videos and classified them into corporate, hospital, education and private. The quality of information was assessed using the Modified DISCERN and JAMA benchmark scores. The search yielded 12 060 videos of which 42 were analyzed. There were 9 (21%) videos from corporate organizations, 12 (29%) from hospitals, 3 (7%) from educational organizations and 18 (43%) by private individuals. The mean Modified DISCERN score was 2.1 ± 1.07 (range 0.3-4) and mean JAMA benchmark score was 0.9 ± 0.65 (range 0-2). Educational videos had highest mean Modified DISCERN score (3.1 ± 0.85) and private videos, the least (1.43 ± 1). This difference was statistically significant (P = 0.004). Hospital videos had highest mean JAMA benchmark score of 1.3 ± 0.6 as compared with private videos which had the least mean score of 0.5 ± 0.6. This difference was also statistically significant (P = 0.001). The results of our study indicate that the quality of information on idiopathic clubfoot on YouTube needs improvement. Videos from educational and hospital sources should be preferred over private sources.

Back pain and school bag weight - a study on Indian children and review of literature.

Back pain in children is a complex phenomenon, which has been shown to be associated with physical and psychosocial factors. None of the studies on Indian children have investigated the possible association between back pain and psychosocial factors. We decided to determine the prevalence of back pain in students and association with both physical and psychosocial factors. A cross-sectional study was conducted on 163 students from two city schools. Physical factors were evaluated using a structured questionnaire. Strengths and difficulties questionnaire was used to assess psychosocial factors. The studied sample consisted of 49.7% boys and 50.3% girls. Mean school bag weight was 6.1±2.4 kg (range: 2.2-15.6 kg). Mean weight of school bag as a percentage of body weight was 13.5±6.2%. Approximately 76% students carried more than 10% of their body weight. The prevalence of back pain (over last 1 month) was 53.9%. No associations were found between back pain and weight of school bag, weight of school bag as a percentage of body weight and physical activities. Significant associations were found between back pain and number of hours spent watching television [odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5; P=0.003], history of injury to the back (OR: 4.8, 95% CI: 1.47-15.8, P=0.003), presence of a family member complaining of back pain (OR: 1.98, 95% CI: 1.25-3.14, P=0.002), conduct (P=0.042) and hyperactivity problems (P=0.045). Thus, there appears a need to consider psychosocial factors along with physical factors when evaluating a young student with back pain.

Paediatric Salter-Harris type IV injury of distal tibia with talus fracture.

Fracture of talus with Salter-Harris injury of the distal end of tibia is a rare injury in paediatric age group. The authors report a case of a 13-year-old male child who sustained type IV Salter-Harris injury to the medial malleolus with coronal spilt along with spilt and depressed fracture of the neck of talus and fracture of the lateral process of talus with stable compression fracture of spine sustained due to fall from 6 meters height. CT scan delineated the morphology of fracture pattern and helped in preoperative planning. Talar articular fracture was reduced and fixed arthroscopically while distal tibial fracture was fixed under image intensifier. We observed favourable outcome following arthroscopic reduction at 4-year follow-up.

A Case Report of an Unusual Case of Tuberculous Osteomyelitis Causing Spontaneous Pathological Fracture of Humerus in a Middle Aged Female.

INTRODUCTION: Tuberculosis is a major health problem worldwide. Extrapulmonary tuberculosis is often secondary to some primary foci in lungs. There are reports of tuberculous osteomyelitis involving maxilla, ulna, femur, and shoulder joint but none have reported pathological fracture in humeral diaphysis due to tuberculosis osteomyelitis without shoulder joint involvement. We report a case of pathological fracture of humerus diaphysis due to tuberculous osteomyelitis with normal articular space. We noticed favorable outcome following surgery and antitubercular drugs. CASE REPORT: A 62-year-old female diabetic patient presented with complaints of pain in the right shoulder of 2 weeks duration and inability to raise right arm. Initial clinical evaluation revealed local rise of temperature, tenderness over the right shoulder and proximal arm and restricted range of movements in all plane. Neurologically, the patient was normal. Erythrocyte sedimentation rate was raised. Computed tomography chest showed small area of consolidation in the left upper lobe. Plain radiograph of the right shoulder with humerus showed transverse fracture of proximal shaft of the right humerus. J-needle biopsy was done from proximal humerus fracture site. Histopathological examination of biopsy tissue from fracture site confirmed granuloma with epithelioid and Langhan's giant cells. Mantoux test and culture for acid-fast bacilli were non-conclusive. Based on histopathology report, we concluded this to be tuberculous osteomyelitis of humerus and the patient was started on category 1 antitubercular drugs, under Revised National Tuberculosis Control Programme as per revised WHO guidelines. We performed open debridement and fixation of fracture with rush nail. Initial follow-up 4 months, post-operative and plain radiograph showed overall improvement in general condition of the patient, weight gain, and good fracture healing. One year following index surgery, rush nails were removed due to pain at insertion site. Fracture healed completely. Shoulder abduction and forward flexion were restricted in terminal 30°, internal and external rotation, and adduction was full compared to opposite shoulder. CONCLUSION: Tuberculosis is very common in India, but its presentation as spontaneous fracture of humerus is unusual. It is highly likely that most orthopedician will encounter and treat tuberculosis and our case highlights the high degree of suspicion one must have in diagnosing pathological fracture of long bones. Error in diagnosis and treatment burdens the medical resources and overall morbidity.

Atypical Presentation of Tuberculosis of Elbow Joint in Operated Case of Distal Humerus Fracture.

INTRODUCTION: A typical presentations of tuberculosis are not uncommon. Periprosthetic infection with tuberculosis after total joint replacement has well published. Tuberculosis of the elbow following open reduction internal fixation of a distal humerus fraeture is extremely rare. CASE REPORT: We report case of a healthy, immunocompetenet 49-year-old male who underwent open reduction and internal fixation with bicolumnar plating for distal humerus fracture and presented after 18 month with cystic swelling over medial aspect of operated site. There was no wound dehiscence and the underlying fracture was healed well without any signs of implant loosening or bony involvement. Cystic swelling was excised and histopathology provided the diagnosis of tuberculosis. Patient was treated with anti tubercular chemotherapy and patient made uneventful recovery. CONCLUSION: Although synovial tuberculosis after fracture fixation is a rare entity, tuberculosis should be kept as a differential diagnosis. Surgeons should have high index of suspicion to diagnose atypical presentations of tuberculosis.

Inter- and intra-observer reliability of measurement of pedicle screw breach assessed by postoperative CT scans.

BACKGROUND: Pedicle screws are used increasingly in spine surgery. Concerns of complications associated with screw breach necessitates accurate pedicle screw placement. Postoperative CT imaging helps to detect screw malposition and assess its severity. However, accuracy is dependent on the reading of the CT scans. Inter- and intra-observer variability could affect the reliability of CT scans to assess multiple screw types and sites. The purpose of this study was to assess the reliability of multi-observer analysis of CT scans for determining pedicle screw breach for various screw types and sites in patients with spinal deformity or degenerative pathologies. METHODS: Axial CT scan images of 23 patients (286 screws) were read by four experienced spine surgeons. Pedicle screw placement was considered 'In' when the screw was fully contained and/or the pedicle wall breach was ≤2 mm. 'Out' was defined as a breach in the medial or lateral pedicle wall >2 mm. Intra-class coefficients (ICC) were calculated to assess the inter- and intra-observer reliability. RESULTS: Marked inter- and intra-observer variability was noticed. The overall inter-observer ICC was 0.45 (95% confidence limits 0.25 to 0.65). The intra-observer ICC was 0.49 (95% confidence limits 0.29 to 0.69). Underlying spinal pathology, screw type, and patient age did not seem to impact the reliability of our CT assessments. CONCLUSION: Our results indicate the evaluation of pedicle screw breach on CT by a single surgeon is highly variable, and care should be taken when using individual CT evaluations of millimeters of breach as a basis for screw removal. This was a Level III study.

Interobserver variability using a commercially available system of archived digital radiography with integrated computer-assisted measurements for scoliosis Cobb angles.

BACKGROUND: The purpose of this study was to determine if digital enhancements could improve upon published and interobserver variability for Cobb angle measurements of idiopathic scoliosis using a commercially available PACS system. The study also sought to determine if experience of the observer affected overall variability and to evaluate the time required to measure Cobb angles using 3 different techniques. As the decision for scoliosis treatment requires serial radiographic measurements by 1 or more observers at different times, precise landmark identification and curve measurement should decrease variability and improve accuracy. METHODS: Fifty-four consecutive digital radiographs of 49 children with idiopathic scoliosis were collected and archived, yielding a total of 117 curves. Five observers, ranging from a PGY2 resident to a senior level faculty member, measured each radiograph in 3 different ways. Technique A involved measuring the curves as the image first appeared on the computer screen. Technique B consisted of 2 extra steps: enlarging the image until the spine filled the screen and using an edge enhancement tool. Technique C utilized the steps in B and further enlarging each vertebra to adjust each measurement. Each technique was timed for each observer. RESULTS: Technique C had the lowest variability that was significantly different from technique A. Technique B also had lower variability than technique A. The 2 observers with the greatest experience demonstrated the least intraobserver and interobserver variability. Techniques B and C decreased the variability of less experienced observers. The average time required for techniques A, B, and C was 25, 29, and 40 seconds, respectively. Confounding variables such as obesity did not affect the measurements, but curve location did, with thoracic curves causing greater variability for less experienced observers. DISCUSSION: The results demonstrate that less experienced observers using the relatively rapid technique A for digital radiographs are more likely to have clinically significant discrepancies in their measurements, which could affect treatment decisions. Taking 4 extra seconds using technique B significantly decreases variability and improves accuracy in the evaluation and management of scoliosis patients. LEVEL OF EVIDENCE: I (testing of previously developed diagnostic criteria).