Review Cutting Edge Orthopaedic Information Enhancing Resident Education

PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA’S

September 2013 ResidentReview Cutting Edge Orthopaedic Information Enhancing Resident Education

Who gets the knife? Technology Corner: By Steven L. Frick, MD, Editor POSNA Educational Resources Review By Orrin Franko, MD “First I will get ready, and then perhaps my chance will come.” As November approaches, many residents may – John Wooden wonder how their mobile devices can help prepare At scrub sinks and OR tables them for the in-training exam. This column will all over the country this provide tips and tricks for utilizing your phone or summer, surgical cases are tablet to study for the OITE. starting and both resident First and foremost, your tablet (iPad, iPad mini, and attending hands are Android, Surface, etc.) is a traveling library. There being held out for scalpels. is now a vast selection of useful tools to manage, Steven L. Frick, MD Who will get the knife? This read, and even annotate or highlight PDFs. Some question is being pondered and of the most popular apps include iAnnotate and hopefully discussed by many orthopaedic residents GoodReader, and both include the ability to save and attending surgeons. Summertime brings an annotated PDFs, share them with colleagues, and sync academic new year, and with it PGY1 residents fluidly with DropBox and many other cloud-based become full-time orthopaedic surgeons, and junior servers. An argument can be made that typically residents become senior residents. These transitions journals and textbooks are not delivered in full-text bring expectations on the part of these residents PDF form, thus making the extra steps somewhat (and their program directors) that they will have cumbersome for transferring documents onto your increasing involvement in surgical cases. iPad or other device. Try this little trick to simplify the So how does this decision get made? There are some steps: residents who feel as if they should always get the 1. Create a DropBox account (free) and add a folder knife, even if they have not done the preparatory to your computer desktop called “Journal Articles.” work to deserve it. And conversely, there are some This will automatically sync the contents of that attendings who will not give up the knife, even to folder with your DropBox. deserving residents. Neither of these situations is 2. Utilizing iAnnotate or GoodReader, allow access desirable- residents who expect to be handed the to your DropBox account and set the app to knife just because they show up, and who complain automatically sync with your new “Journal and pout rather than learn to be a good assistant, Articles” folder. can be poisonous to the morale of a residency program. Attendings who never allow residents to 3. Google Chrome web browser allows you to view and perform the difficult parts of cases do the residents save PDF files directly from the browsing window, in their program a disservice, give the program without having to open Adobe Reader. When you a bad reputation, and fail to fulfill their societal find an interesting article online, save it directly to obligation to pass on their knowledge and skills to the “Journal Articles” folder on your desktop. the next generation. 4. These three steps take about 10 minutes to set up Here is a “top-ten” list I consider before giving and saving PDF articles takes about 5 seconds. Now the knife to the resident to perform the technical your tablet will always have the most updated parts of a surgical procedure. If you are a resident PDFs that you have selected for mobile viewing. helping me in the OR today, if you can answer these ** An additional tip: many new textbooks include a questions it is likely you will be doing the case. code for “online access.” While most of these sites do

continued on page 2 continued on page 6 Who gets the knife? (from page 1)

1. Who gets the knife? This time the 5. What constitutes good soft tissue 9. What will we be worried about just question is from the perspective of handling technique? How do after the surgery? Good surgeons the patient- in other words, what technically excellent surgeons see their patients whenever are the indications for surgery? Why move from skin to bone, efficiently possible in the recovery room are we in the operating room today? and with minimal blood loss and and early the day after surgery. What are the risks and benefits of soft tissue injury? The ability to get If I don’t see you doing postop today’s surgical procedure? While good exposure and visualization checks to document intact function a discussion of the alternatives is critical in technically excellent distal to the surgery site, or if I should not be held on the day of the surgery- how to use retractors beat you to the patient frequently operation, the resident should know effectively and proper involvement for rounds, I will question your what they are. of surgical assistants is very commitment and be less likely to 2. What is under the skin incision? important. give you the knife next time. Have a good knowledge of the 6. What are the hard tissue 10. What are the expected results anatomy of the region, especially maneuvers to consider? Will this from today’s surgery? What the nerves and arteries in the be fracture surgery where exposure does the literature say about this region of the approach. Understand of the fracture fragments while procedure for this diagnosis? the approach and the anatomic preserving soft tissues, followed by Residents should be familiar with intervals that will be used to “get to anatomic reduction, is important, what is written in our literature the bone.” or is it an osteotomy with about the outcomes of the 3. What is the plan? Have a realignment of major fragments? procedure, and be knowledgeable preoperative plan for how you The ability of the resident to about the strength of the evidence. are going to accomplish today’s appreciate the three dimensional Our system of educating surgeons surgery. Having the wrong plan nature of many of our surgeries, still largely follows Halstedian won’t keep you from getting the and adjust as needed, is critical. Get principles, and one of the most knife in my room, but having no to bone and stay there is a tried and critical is the concept of graduated plan likely will. The plan should true maxim in orthopaedics- place responsibility (residents assuming consider what equipment will be retractors to protect the soft tissues, more and more responsibility as time needed, what imaging should be then do good carpentry. passes during residency, which in available, any medical or anesthetic 7. How are you at closing the wound? surgical specialties means residents considerations, how to position A resident who cannot efficiently actually doing more and more of the the patient, and the type and close a wound, with good soft surgical procedures). Accomplishing placement of implants. tissue technique and cosmesis, is this over the five-year period of 4. What is “plan B?” Having a not likely to get the knife on the residency requires work on the part backup plan in mind, especially for next case of the day. If you are slow, of both residents and attendings. fracture and reconstruction cases, is practice and become efficient. One Above is my list of prerequisites for evidence of a prepared surgeon. of my mentors used to say surgical residents to get “playing time” in the time for opening and closing the OR- bring it up with your attending wound should be 5% for each. and see what their list looks like- and 8. What will the postoperative if you want the “get the knife,” then protocol be? A good surgeon has get ready. As another of my mentors an understanding of the triphasic Dick Gross has written- “Surgery nature of orthopaedic surgery- 1) is too important to leave to the preoperative evaluation, workup unprepared.” and planning, 2) excellent execution of the surgical plan, and 3) postoperative care and rehabilitation.

2 Interview with Peter Newton, MD: Immediate Past President of POSNA By Brian Scannell, MD

1. In your year as POSNA Balance is something I achieve president, what issue or issues more often in my patients’ spine did you have to deal with that than in my own life, but I’m were the most important? working on getting balance in I came to the presidential line both 100% of the time. I do my from the perspective of a past best to make sure the things I do, treasurer of POSNA and so the I love to do. This doesn’t mean “no money, no mission” motto these roles don’t compete and for had special meaning. I wanted to sure there is a priority that puts be absolutely certain the board some in front of others. Trying to had mechanisms in place to know define the time for each role helps and understand the financial and not unlike the sock drawer, when new ones come in, old ones position of the organization. Peter O. Newton, MD. Philanthropy is an important have to go. I think you have to personal goal for Cathy and me; expect the roles and jobs to evolve 4. What do you do for fun? as you evolve through your as such I hoped to create meaning If you do it right, it’s all fun! for the donations made by our career; getting them to all balance all the time is tough. Keep the Seeing patients back after they members. One of the important are healed and on with their additions in my view this past things nearest and dearest to you at the top of the pile. life is fun. Fixing a spine in the year was the expanded donations OR is fun. Yucking it up with and financial commitment that my POSNA presidential line were focused on research. There “...I’m working on buddies hoping to give the society are now 10 grants per year, each direction is fun. Discovering with up to $30,000 in funding as getting balance in both and sharing what the future well as a newly launched $100,000 100% of the time. I do my holds for scoliosis care is fun. grant available to improve the It’s (mostly) all fun. Outside of quality and safety of pediatric best to make sure the things work I enjoy projects around the orthopedic clinical care. The other yard and in the garage. My son very important task centered on I do, I love to do. ” Walker and I have been working reinforcing the relationships we on restoring a Triumph Spitfire. have with our global pediatric It has been a great project that orthopedic society partners. I am 3. Follow up question = goes in fits and spurts based on very happy that along with the Do you sleep? my travel and his homework, POSNA office staff, Peter Waters Unfortunately the day only has but we have a running sports car and I were able to nail down the 24 hours and no matter how that we are both proud of (even details with our colleagues at you slice it, sleep takes its piece if we can’t get it to pass CA smog EPOS for a combined meeting of of the daily pie. I wish I could standards…). I try to get some our 2 societies in 2017 (Barcelona). survive on less and occasionally time to myself with a weekend We are also partnering in Asia and I pretend I’m one of those folks walk/jog/hike. I rerun some of South America on educational that only needs 4-5 hours a night. the week’s events, think big, think meeting in the months and years I’m OK like that for short stents, small and generally let my mind ahead. but I always have to pay back the go where it wants. Sometimes I 2. How do you prioritize and “sleep bank,” often with interest. come home with a to-do list for balance your many roles Sunday afternoon is when I get the week and sometimes I just (surgeon, researcher, consultant, caught up. come back tired. At some point administrator, POSNA president, I’d like to become a good enough family man, etc)? surfer that I could accomplish this

continued on page 4

3 Interview with Peter Newton, MD (from page 3)

on the water as well, but at this and when I started practice modulation in the spine has point I’m too preoccupied with all offered encouragement the greatest potential to change the task of standing up to get any academically. Developing and scoliosis care. The potential to thinking done. Fishing is the other maintaining relationships with correct scoliosis without a fusion activity I will always say yes to, mentors is something we all procedure is very exciting to me, flies on a stream or trolling in the need, no matter where in our and I think we may see that as Pacific. career we are. Given what truly possible in the near future. 5. How did you first become POSNA is and does, I didn’t Having said that we are doing involved in POSNA early in need much encouragement to get much better with our fusion your career? involved. I have always found surgery and working with the my involvement to create a great Harms Study Group has been I don’t actually recall. POSNA has sense of honor and pride. extremely valuable for me as been a part of my professional life a surgeon. The collaboration as long as I can remember. I’m 7. In your training what drove you towards more of a spine practice? of peers around the globe has sure I started out by submitting resulted in many great ideas on papers to the annual meeting. I was intrigued by scoliosis how to analyze and improve One year the program committee after seeing my first CD (Cotrel what we do as scoliosis surgeons. accepted one. Eventually I was Dubousset) instrumentation as Working with a team is almost on the program committee. I’d a resident. Deformity correction always better than working as an say in looking back that I got is at the heart of pediatric individual. involved from the scientific side orthopedics, and I was sold on of POSNA, but there are many it both from the extremity and 9. What will scoliosis treatment be sides to POSNA for members to spinal side. When I started in like in 10 years? become involved. The council practice, Ilizarov limb deformity I can envision very different structure of the organization gives correction and scoliosis correction scoliosis treatment 10 years from some insight to how POSNA were evolving fields that I jumped now, but the biggest changes will organizes itself and prioritizes its into. With time, my experience require an understanding of the activities: Education, Research, with thoracoscopic spinal surgery etiology. Knowing AIS is a genetic Communication, Health Care drew me deeper into scoliosis. My condition gives me hope that Delivery, Treasurer’s, Secretary’s research went that way as well, with the rapidly advancing field and President’s. There are over and one thing led to another. Now of genomics that we will soon 35 committees and 300+ positions the OR folks ask if I still have understand the pathways that available each year for members privileges when I try to operate lead to altered spinal growth of so to volunteer, and volunteer they on a leg. By the way, I do. many teens. Understanding the do. Unfortunately there are physiology opens the possibilities always more members interested to medical treatments in a world than positions available. If where only mechanical solutions you are looking to participate, “Developing and exist today. As much as I’d like keep volunteering and don’t be maintaining relationships to think that 10 years is a long discouraged. The AAOS and the enough time for such discovery, AAP, Section on Orthopedics with mentors is something it likely is not. As such we will also have opportunities to get likely remain in the mechanical involved in a professional society. we all need...” world of scoliosis correction 6. Who were some of the people for much longer. I would hope that influenced you to pursue an that in 10 years the fusionless active role within POSNA? 8. Of your research contributions, growth modulation options of treatment are understood well My mentors at many levels which is the most significant to you? Why? enough and effective enough helped me see and understand to become commonplace. I also the importance of research and I hope my most significant believe the 3 dimensional imaging education in addition to clinical contribution is still to come… For and assessment of scoliosis will practice, and these same folks now I think the work our research be far enough along that the both from residency, fellowship group has done on growth selection of fusion levels and

4 Interview with Peter Newton, MD (from page 4)

correction strategies will be more us all. Where do you want to be and possibly hip as the years go, standardized. It is very clear to on that spectrum? The bigger depending on the strengths of me that we have far too much art the community and practice the their initial fellowship. The first and not enough science in how more likely subspecialization several years of practice should we as a community of surgeons makes sense. It also seems the be considered a “fellowship” with treat scoliosis at this time. The younger the surgeon the more your senior partners helping. screws, hooks, rods and tools to likely the tendency towards Please don’t think you are do the work are similar, but the subspecialization. supposed to have learned it all actual methods each surgeon 12. Are there going to be Peds Spine, by the last day of fellowship, no uses to apply them vary widely. matter how many you do. With Early onset scoliosis is another that definition we all do at least 2 unsolved problem, with lots “Treating 4 to help 1 fellowships. of room for improvement and suggests much room for 14. In regards to fellowship training, discovery. I believe the variation what is best for the trainees but will be less and the quality greater improvement...” also best for the community and 10 years from now in both EOS patients? and AIS. What is best for everyone 10. Do you believe bracing for AIS Peds Hip, Peds Hand, Peds is finding the right mix of works? If so, in which patients? Sports fellowships? “generalist” and “subspecialist” Yes bracing works! We just The mechanisms for folks to for the specific community. There don’t know how to choose the get specialized training will is room for a subspecialist in right patient to brace. For many likely vary and some pediatric the big city, and a need for the we now brace with standard subspecialty fellowships will and generalist in both big and small indications (Cobb 25-45, Risser do exist. Are these enough to get cities. <2), about half don’t progress the rest of the Peds Ortho general 15. Is there still a role for the general because they weren’t going training required to function pediatric orthopedic surgeon? to. There is another quarter of in a Peds Ortho group where the patients who are braced call needs to be covered? In our As implied above, absolutely! that progress despite the brace. practice we have had folks do It is unlikely there will be a Skipping the brace for those that additional subspecialty training fellowship in muscular dystrophy, won’t progress without it as well after completing their Peds osteogenesis imperfecta, or as those that will progress despite Ortho fellowship, as well as folks Morquio’s. Who is going to it is what we need for brace join our group after completing understand these conditions treatment to improve. Treating a more traditional specialty if we completely subdivide 4 to help 1 suggests much room fellowship (spine, sports). The the pediatric patents into their for improvement; I just can’t pick second path involves on the job anatomic parts? The generalist/ them out the one at this point. general Peds Ortho training, subspecialist dilemma that particularly for trauma and faces pediatric orthopedics is 11. With all of the specialization very similar to that which faces happening in Peds Ortho, where infection care that is typical of a night on call at our center. I think orthopedics and medicine in do you envision the fellowship general. We need both. process going? either path can work. 16. Do you think we will eventually I do think subspecialization in 13. Are people going to have to do 2 fellowships? have CAQs for pediatric Peds Ortho is here to stay. The orthopaedics and for pediatric fields are advancing too fast in There is certainly an increasing ortho subspecialties like spine too many directions for a single trend in applicants planning on deformity? pediatric orthopedic surgeon two fellowships. I don’t think to be proficient in everything. two fellowships will be required, I think this is unlikely in the near The choice of knowing/ although those coming through to mid-term. There are pros and practicing “almost nothing about the Peds Ortho fellowship first cons to the certificate of special everything” or “everything path are likely to want more qualification pathway, and the about almost nothing” plagues training in spine, sports, hand gain in quality (real or perceived)

continued on page 6

5 Interview with Peter Newton, MD (from page 5)

is of course the goal. There are a too many patients with intoeing. going to have a bigger role in number of methods to maintain Get to the developing countries medicine and this extends to quality in our specialty training, and the differences are striking. our specialty as well. Given and POSNA remains committed The disparities that exist around we are surgical specialty and to helping attain the highest the globe in pediatric orthopedic the midlevel providers are not quality in pediatric orthopedic care are vast. Traveling the world surgeons, there is great potential training with or without a CAQ. to experience the lives of your to have MLP fill many of the 17. Do we need more pediatric peers is one of the benefits of non-operative roles. Our group of ortho fellowships, or do we being one of the “haves.” Take 10 is currently outnumbered by have enough? advantage of the opportunities MLPs who help us manage the to travel. Attend one of POSNA’s non-surgical side of the business. The fellowship seekers will global partners meeting (EPOS Common nonoperative problems, determine if we have enough - Europe, SLAOTI – South as well as nonoperative trauma fellowships. I think the market America, APOA – Asia Pacific) to care, are where we currently focus adjusts pretty well and I suspect experience the similarities and the our MLPs efforts. The potential we are about right. differences, but more importantly roles are many and will vary 18. How is pediatric orthopaedics meet a colleague on the other depending on the experience in North America different from side of an ocean. Travel to an of the individual and the needs how it is practiced abroad? underserved region and really get of the practice. These folks are a dose of reality. very important to our field and In the developed countries I’d I am glad they now have an say it’s pretty similar, taking 19. What is the role of midlevel opportunity to become members into account the differences in providers in pediatric of POSNA. how health care is generally orthopaedics? administered. We all think we see Mid level providers are clearly

Technology Corner: POSNA Educational Resources Review (from page 1) not directly permit book chapters to ($70 for non-member residents). is somewhat primitive by current be saved as PDF, they typically allow The flashcards are available through standards, but it contains all of the you to “print” a chapter. Google Quizlet, an online flashcard database same useful features found on the Chrome browser also allows you to that allows you to sync the data with full site: fact review, images with “print” directly to PDF, thus allowing any of at least 30 flashcard apps descriptions, in-text cross-referencing for a 1-step solution to transfer your (typically free or less than $2). To sign to images and questions, and full online textbooks subscriptions to up for this unique and useful service, QBank tests with answers (either your tablet. visit this link: http://fs17.formsite. testing or VEQTR learning mode). Many residents utilize the AAOS com/COAA/flashcards/index.html or Many residents may find this useful Orthopaedic Knowledge Update v10 learn more at www.coa.org. during down time in or out of the to assist with OITE and board study, Most, if not all, residents are hospital. but the books lack a supplementary familiar with OrthoBullets as a I hope you find these suggestions question bank. Thankfully, the free and comprehensive question useful for your OITE and board California Orthopaedic Association bank with review facts, images, preparation. Good luck! has developed their own QBank questions, and answers. However, based directly from the book text and you may not know that the site has have made it available to residents for a mobile version for “on the go” test only $40 for COA resident members preparation. Admittedly the site

6 Interview With Randall Loder, MD: Management Of Slipped Capital Femoral Epiphysis At Riley Children’s Hospital, Indianapolis By Christine Caltoum, MD

1. What is the definition of an 5. What is your post-operative unstable slipped capital femoral regimen? epiphysis? 6 weeks non-weight bearing Inability to walk with or without on the affected limb, followed crutches. by protected weight bearing if 2. Do you consider this a surgical callous visible at 6 week mark, emergency? return to activities at 3 months. Yes. 6. Do you routinely take out SCFE implants? 3. How many hours do you consider it “safe” to wait before No. SCFE implants are not going to the OR? routinely removed. The screws are only removed in cases of AVN There is no good objective data on when the tip of the screw may this subject. The patient should become intra-articular as the bone be treated within 24 hours if collapses. possible. I would not compromise Comments by Dr Caltoum: Classic clinical evidence, is that patients NPO status to take to OR but treated for unstable slips do well as would ideally like to get the study by Dr. Loder demonstrated a 47% AVN rate when calculated with long as they do not go on to AVN. A patient to the operating room very small percentage of his patients ASAP. a 2 year follow-up. Most patients who went on to AVN did so within have required second procedures. 4. What is your surgical treatment the first 3-4 months post-injury. If the Following are preoperative, algorithm? AVN rate was calculated at 1-year intraoperative, and postoperative 1) Gentle repositioning of the limb follow-up when there was a larger images of a typical unstable SCFE on the fracture table. cohort of patients (to include those patient. doing well that had not been lost 2) Fixation of the SCFE with 2 to follow-up), the AVN rate was screws (Dr Loder uses 6.5 mm closer to 30%. The complication cannulated screws). that Dr. Loder seeks to avoid is 3) Hip joint decompression avascular necrosis as he feels that through instrumentation incision, other problems such as impingement documented fluoroscopically with can be treated while AVN cannot. the use of a Cobb or large Kelly When asked specifically, Dr. Loder’s clamp. impression, while not backed by

7 Interview With David Podeszwa, MD: Treatment Of Unstable Slipped Capital Femoral Epiphysis At Texas Scottish Rite Hospital For Children By Anthony Riccio, MD

1. What do you see is the role on the Loder Classification. If If an open reduction is performed, for surgical dislocation of the the patient does not have the it is performed using the hip in the management of the ability to bear weight, then Modified Dunn technique unstable slipped capital femoral we consider that slip unstable. described by Leunig and Ganz. epiphysis? These kids usually present in a Reduction is typically performed The exact indication for an open very typical manner, with some while monitoring the blood flow reduction of an unstable SCFE prodromic pain, whether for a to the femoral epiphysis using an has not been fully established. few days, a few weeks or even intra-cranial pressure monitor. Several questions still need a few months. Then there is an Fixation of the femoral epiphysis to be answered: Who is the episode that results in severe pain is performed using two 6.5 mm ideal candidate? What is the and the inability to bear weight. fully threaded cannulated screws. rate of AVN? When should We then confirm that we have The failure of fixation in a patient the procedure be performed? appropriate imaging - an AP early in our experience was with Who should be performing the pelvis x-ray and a lateral of the 4.5 mm cannulated screws. Post- procedure? contralateral hip. These patients operatively, the patient remains are kept on bed rest. We treat foot flat weight bearing for 3 There is still no definitive data them urgently, as you would months. available which provides the rate an open fracture. If we have 3. You and Dan Sucato are of AVN from an open reduction the opportunity to treat them of an unstable SCFE. There have currently conducting a right away, we will. However, if prospective randomized trial on been relatively small retrospective it is two or three o’clock in the studies of the open reduction but unstable slips. Could you tell us morning, we will wait until we a little bit about your research? we still lack the experience we have the appropriate facilities and have with in-situ pinning. appropriate team together the Several years ago, we started a A severely displaced slipped following morning. randomized trial to answer the capital femoral epiphysis, if question: “Is there a higher AVN pinned in-situ, can result in rate in open reduction versus significant residual deformity and “Is there a higher AVN rate insitu pinning?” When a patient significantly restricted motion in open reduction versus presents to our emergency and/or femoral acetabular department with an unstable impingement. We know that, with insitu pinning?” slip, either Dr. Sucato or I discuss time, the severe slipped capital the study and risk/benefits of femoral epiphysis will develop both procedures with the family and ask them to participate. If labral and articular cartilage If we perform an in-situ pinning, injury. Therefore, the theoretical they agree, we open an envelope there is no reduction maneuver which randomly tells us whether role open reduction is restoration performed. The patient is of anatomic or near anatomic we are going to perform an in-situ placed on the fracture table and pinning or an open reduction. alignment, maintenance of the reduction we obtain from range of motion and prevention If the family chooses not to positioning is what we accept. participate, then each procedure or limitation of intra-articular They undergo in-situ pinning damage. is discussed again and the family with two fully-threaded 6.5 mm decides which procedure will be 2. When an unstable SCFE comes cannulated screws and some form performed. Whether the family into Texas Scottish Rite Hospital, of a capsulotomy. Whether it’s a chooses to participate or not, how is it treated? formal capsulotomy, an aspiration there is no change in the timing of of the hip or using a hemostat Confirming the diagnosis is surgery or how it is performed. to open the capsule, it’s surgeon the first step. The diagnosis preference. of an unstable slip is based

continued on page 19

8 Challenging Cases: Pediatric Musculoskeletal Trauma

Question 1 recurvatum; no loss of reduction was Preferred Response: C noted in the valgus or procurvatum Discussion: The most likely P.J. is a 7yo female who injured her groups. The vast majority of children diagnosis is a minimally displaced right tibia in a horseriding accident. with isolated uncomplicated tibia spiral tibia fracture, also known as She was noted to have an isolated fractures can be managed in a a toddler’s fracture. The fracture closed distal tibial shaft fracture, closed fashion. External fixation is can be subtle on initial presentation, an intact fibula, and 5 degrees of reserved situations with extensive however, followup radiographs will varus angulation. She was admitted comminution, multitrauma, or severe demonstrate periosteal new bone overnight for observation for a soft tissue compromise. ORIF is formation indicating the presence of compartment syndrome. She did associated with wound problems and a fracture. Treatment is conservative, well overnight with minimal pain, is rarely indicated in children. the fracture rarely displaces, and and underwent fracture stabilization References: the long term prognosis is excellent. the next day. Which option 1. Yang JP, Letts RM: Isolated The fact that he is crawling suggests represents the preferred management that the pathology is distal to the for the aforementioned fracture? fractures of the tibia with intact fibula in children: a review of 95 knee, making hip septic arthritis or A. Long leg cast application, patients. J Pediatr Orthop 1997; toxic synovitis less likely. The acute followup in 4-6 weeks 17(3): 347-351. nature of the injury and the lack of systemic symptoms points away from B. Long leg cast application, 2. Mashru RP, Herman MJ, Pizzutillo infection or tumor; however, if the followup in 1-2 weeks PD: Tibial shaft fractures in child’s condition does not improve as C. Open reduction and internal children and adolescents. J Am expected, a bone scan or MRI may be fixation with a compression plate Acad Orthop Surg. 2005; 13(5): indicated. and screw construct 345-352. References: D. External fixation Question 2 1. Tachdjian’s Pediatric Orthopaedics, Preferred Response: B 4th Ed. Philadelphia: Saunders Discussion: The patient has a C.J. is a 2+9 yo male who was in Elsevier, 2008: 2720. distal tibial shaft fracture with good health until 3 days ago, when 2. Skaggs DL, Flynn JM. Staying an intact fibula. The amount of he tripped while running on level out of Trouble in Pediatric fracture angulation on presentation ground. He has refused to bear Orthopaedics. Philadelphia: is acceptable, however, these weight on his left leg since then, Lippincott Williams & Wilkins, fractures have a propensity to fall he “stands like a stork” when the 2006: 124-125. into varus and recurvatum despite parents attempt to entice him to walk. cast immobilization. Yang and Parents deny any fevers or systemic Question 3 Letts reported on 95 isolated tibia symptoms. He is comfortable at rest fractures with an intact fibula. and he will crawl on both legs, just R.Y. is a 4yo female who fell while Out of 76 patients with initial not stand or walk. Clinical exam jumping on the bed onto his right fracture angulation, 61% had varus reveals no swelling or bruising, arm. He sustained an isolated injury angulation, 25% had recurvatum, and he is distally neurologically to his elbow. An AP view of his right 8% had valgus, and 7% had and vascularly intact. Xrays of his elbow is shown below. He is distally procurvatum. They theorized that left lower extremity are read as neurologically and vascularly intact the propensity to varus was due normal. Which option represents and comfortable at rest. Fracture to the splinting effect of the intact the preferred management of this displacement is approximately fibula as well as the varus force patient? 1-2mm. Which option represents produced by the posterior tibialis A. Bilateral hip ultrasound the preferred management for the muscle and toe flexor and extensors. aforementioned injury? 32 of the 76 patients (42%) had some B. Bone scan recurrence of the deformity even after C. Long leg cast immobilization with A. Long arm cast application and closed reduction and casting. All followup radiographs in 2-3 weeks followup in 1-2 weeks recurrences involved varus and/or D. MRI B. Long arm cast application and continued on page 10

9 Challenging Cases: Pediatric Musculoskeletal Trauma (from page 9)

followup in 4-6 weeks 2. Song KS, Waters PM. Lateral occur with severe fishtail deformities, C. Open reduction and internal condylar humerus fractures: which which rarely occurs with lateral fixation ones should we fix? J Pediatr condyle fractures, but this is Orthop 2012; 32(Suppl 1): S5-9. distinctly uncommon. D. MRI 3. Horn BD, Herman MJ, Crisci K, References: Correct Answer: A Pizzutillo PD, MacEwen GD. 1. Tachdjian’s Pediatric Fractures of the lateral humeral Orthopaedics, 4th Ed. condyle: role of the cartilage hinge Philadelphia: Saunders Elsevier, in fracture stability. J Pediatr 2008: 2486-2496. Orthop 2002; 22(1): 8-11. 2. Cates RA, Mehlman CT. Growth 4. Finnbogason T, Karlsson G, arrest of the capitellar physis after Lindberg L, Mortensson W. displaced lateral condyle fractures Nondisplaced and minimally in children. J Pediatr Orthop displaced fractures of the lateral 2012; 32(8): e57-e62. Discussion: The patient has a lateral humeral condyle in children: 3. Pribaz JR, Bernthal NM, Wong condyle fracture that is displaced a prospective radiographic TC, Silva M. Lateral spurring approximately 1-2mm. Tachdjian’s investigation of fracture stability. J (overgrowth) after pediatric Pediatric Orthopaedics textbook Pediatr Orthop 1995; 15(4): 422-425 lateral condyle fractures. J Pediatr states “lateral condyle fractures may Orthop 2012; 32(5): 456-460. be difficult to diagnose and have a Question 4 propensity for late displacement, 4. Glotzbecker MP, Bae DS, factors that make their treatment L.R. is a 5yo male who sustained Links AC, Waters PM. Fishtail perilous.” Fracture stability is a widely displaced lateral deformity of the distal humerus: primarily determined by the presence condyle fracture. He was taken a report of 15 cases. J Pediatr or absence of an intact cartilage to the operating room for open Orthop 2013; epublished ahead hinge, a parameter which is difficult reduction and internal fixation of of print. to evaluate by plain radiographs the fracture via a lateral approach. alone. Close followup is necessary Intraoperatively, the articular Question 5 to prevent the sequelae of a cartilage was anatomically reduced. malreduced lateral condyle fracture. Some plastic deformation of the A patient sustained a twisting injury Repeat radiographs at 1-2 weeks lateral cortex was noted. When to the left ankle. The patient then are recommended; cast removal counseling the family, which underwent an initial radiograph and may be necessary to adequately complication would be the LEAST closed reduction followed by the visualize the fracture. Most pediatric likely to occur? CT scan seen in Figure 1 and 2. In orthopaedic surgeons agree that open A. Growth arrest what age group is this injury most reduction and internal fixation or commonly seen, and why does it closed reduction and percutaneous B. Cubitus varus occur in this age group? pinning should be performed for C. Delayed union A. Late adolescent (age ~16-18yo); fractures that are displaced more than D. Lateral spur formation asymmetric closure of the physis 2mm, as these fractures do extend (medial, central, lateral) into the elbow joint. MRI has been E. Late radial head dislocation used to determine the integrity of Preferred Response: E B. Late adolescent (age ~16-18yo); the cartilage hinge, but the need for closed distal tibia physis Delayed union is a common conscious sedation in young children C. Early adolescent (age ~12-15yo); makes this option less attractive. complication of displaced lateral condyle fractures, likely due to asymmetric closure of the physis References: poor blood supply. Cubitus varus (medial, central, lateral) 1. Tachdjian’s Pediatric may result from malunion, growth D. Early adolescent (age ~12-15yo); Orthopaedics, 4th Ed. stimulation, or lateral spur formation, asymmetric closure of the physis Philadelphia: Saunders Elsevier, which can give the appearance of (central, medial, lateral) 2008: 2486-2496. varus. Growth arrest with cubitus E. Pre-adolescent (age 8-10yo); open valgus is rare, but has been described. distal tibia physis Late radial head dislocation can Preferred answer: D

10 Challenging Cases: Pediatric Musculoskeletal Trauma (from page 10

Fig. 1 Fig. 2 Question 6 Fig. 1 Fig. 2

A 3-year old girl with knee pain and mild swelling after a fall presents to clinic with tenderness and a normal neurological and vascular examination. Radiographs demonstrate the fracture seen in Figure 1. Treatment in a long leg The triplane fracture is commonly cast following a gentle reduction is referred to as a “transitional instituted with uneventful fracture fracture.” Prior to complete distal healing. Nine months from the time tibia physeal closure, there is of injury, the child’s parents return period lasting approximately 18 with complaints of a progressive This patient has post-traumatic tibia months in which the physis closes knee deformity involving the affected valga resulting from her proximal in a consistent pattern: central, extremity. Radiographs are shown in metaphyseal tibia fracture (frequently anteromedial, posteromedial, and Figure 2. The appropriate course of referred to as a “Cozen fracture”). finally lateral.1 Because of this action at this time is: Progressive genu valgum following pattern of physeal closure, the proximal metaphyseal tibia fractures fracture typically occurs in children A. High tibial osteotomy for acute in children is fairly common. The ~12-15yo (Mean age of 14.8yo in deformity correction. deformity progresses most rapidly males and 12.8yo in females)2. Initial B. Proximal tibial epiphyseodesis during the first year following the radiographic findings demonstrate to prevent further progression injury and often continues to progress a Salter Harris type III fracture on of deformity with staged tibial at a slower rate for an additional 12 to the anteroposterior radiograph lengthening and deformity 18 months. and a Salter Harris type II fracture correction via distraction the lateral radiograph. After osteogenesis as the child nears The exact etiology of the deformity initial closed reduction, a CT scan skeletal maturity. remains unclear. Though several theories exist regarding the cause of is often indicated. Nondisplaced C. Proximal medial tibial physeal the Cozen phenomenon (inadequate fractures with less than 2mm of growth plate tethering (guided reduction, medial soft tissue joint displacement as well as extra- growth) to allow for gradual interposition at the fracture site, articular fractures can be treatment deformity correction with immobilization (typically soft tissue imbalance due to lateral initial long leg cast). Intra-articular D. Application of a lower extremity tethering by the iliotibial band, lateral displaced fractures of >2mm typically unloader brace to reduce physeal tethering by the intact fibula require open reduction and internal compression across the lateral and unrecognized Salter Harris V fixation. proximal tibial physis and injury to the lateral tibial physis), stimulate deformity correction asymmetric physeal growth due to References: via accelerated lateral tibial differential stimulation of the medial 1. Schnetzler K, Hoernschemeyer growth. tibial physis by hypervascularity or D. The Pediatric Triplane Ankle E. Observation with expectation growth acceleration secondary to Fracture. Journal of the American for spontaneous deformity normal fracture healing is widely Academy of Orthopaedic correction. accepted as generating the valgus Surgeons. 2007; 15:738-747. deformity. Answer: E 2. Karrholm J. The triplane fracture: In a long term follow-up study of four years of follow-up of 21 cases patients with post-traumatic tibia and review of the literature. J valga, Tuten et al. demonstrated Pediatr Orthop B. 1997; 6(2): 91-102 spontaneous correction of the deformity and clinically well aligned limbs at an average follow-up of 15 years from injury. As the majority of patients will spontaneously correct their tibial alignment with continued continued on page 10

11 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 9) growth, interventions for deformity radial or ulnar pulse present in the loss of perfusion or pulse after correction are not indicated until the emergency department. He is able to reduction, indicating an entrapment child has been granted a prolonged flex the DIP of his index finger and of the neurovascular structures at time period to allow spontaneous the IP joint of the thumb but will not the fracture site. Open reduction correction to occur. Lastly, as extend his index finger. Radiographs is not indicated in the setting of a this deformity occurs relatively of the injury are shown in the figures perfused hand unless an anatomic frequently following proximal tibial 1A and 1B. You decide to take him reduction cannot be obtained. If metaphyseal fractures, it behooves urgently to the operating room. The there is gapping at the fracture site the treating physician to counsel most appropriate management in the when attempting closed reduction, parents regarding the possibility operating room includes: the surgeon should convert to an of tibia valgum at the initiation of A. Closed reduction with placement open approach to ensure that the fracture treatment. of a well-molded long arm cast if neurovascular structures are not References: reduction is adequate entrapped at the fracture. Closed reduction and casting is not an 1. Cozen L. Fracture of the proximal B. Closed reduction with appropriate management strategy portion of the tibia followed by percutaneous pin fixation, for Type III fractures due to problems valgus deformity. Surg Gynecol accepting slight gapping at with maintaining a reduction and the Obstet. 1953 97: 183-8. the fracture site if alignment risks of complications due to swelling 2. Jordan SE, Alonso JE, Cook FF. is appropriate and the hand in a cast with the elbow in a flexed The etiology of valgus angulation remains perfused, followed by position to maintain reduction, such after metaphyseal fractures of close observation for 24 hours as compartment syndrome. The the tibia in children. J Pediatr C. Closed reduction and pin patient who has a perfused hand but Orthop. 1987 Jul-Aug;8(3):306-10. fixation followed by on table no pulse should be monitored closely as an inpatient for 24 hours to ensure 3. Tuten HR, Keeler KA, Gabos arteriography to look for arterial continued perfusion and no signs of PG, Zionts LE, MacKenzie WG. injury if pulse does not return ischemia or compartment syndrome. Posttraumatic tibia valgain D. Closed reduction with pin children. A long-term follow-up fixation only if an anatomic References: note. J Bone Joint Surg Am. 1999 reduction is obtained, followed 1. Flynn JM, Sarwark JF, Waters Jun;81(6): 799-810. by close observation for 24 hours PM, Bae DS, and Lemke LP. 4. Zionts LE, Harcke HT, Brooks E. Open reduction with exploration The operative management of KM, MacEwan GD. Postraumatic of the neurovascular structures pediatric fractures of the upper tibia valga : a case demonstrating via an approach in the antecubital extremity. J Bone Joint Surg Am asymmetric activity at the fossa 2002; 84(11): 2078-2089. proximal growth plate on Preferred Response: D 2. Sabharwal S et al. Management technetium bone scan. . 1987 Jul- of pulseless pink hand in Aug;7(4): 458-62 Fig. 1 Fig. 2 pediatric supracondylar fractures 5. Zionts LE, MacEwen GD. of humerus. J Pediatr Orthop. Spontaneous improvement of 1997; 17: 303-310. post-traumatic tibia valga. J Bone Joint Surg Am. 1986 Jun;68(5): Question 8 680-7. A 15 year old basketball player has Question 7 acute onset knee pain after trying to Treatment of the “pink pulseless” dunk. He is taken to the emergency A 6-year-old male presents to supracondylar humerus fracture is a department where the following the emergency department after controversial topic. Arteriography x-ray and advanced imaging is sustaining a fall from the swing at is generally not warranted as the obtained (Figures 2A and 2B). The the local playground. He has pain location of the injury is known. family should be counseled on the and obvious deformity to his right Indications for open reduction with potential for which of the following elbow. The patient’s fingers are pink exploration include a previously injuries associated with this fracture and perfused, but there is no palpable perfused extremity with acute pattern:

12 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 10)

A. Premature physeal closure significantly younger with growth causing a recurvatum deformity plates open posteriorly, this would B. Compartment syndrome of the be a concern. Concomitant tearing anterior compartment of the anterior cruciate ligament has not been routinely described with this C. Concomitant anterior cruciate injury. Also, because of the growth ligament disruption plate closure from medial to lateral, D. Medial meniscal tear the fracture usually extends into the lateral joint so lateral meniscal tearing E. Medial meniscus entrapment in and entrapment could occur, not the fracture Spica casting remains the standard of medial meniscal entrapment. Preferred Response: B care for diaphyseal femur fractures References: in this age group. Spica casting has Fig. 1 Fig. 2 1. Pandya NK et al. Tibial tubercle been shown to be effective when fractures: Complications, the cast is placed by experienced classifications and the need for personnel while the patient is relaxed intra-articular assessment. J and sedated. Immediate spica casting Pediatr Orthop. 2012; 32(8): 749- has not been shown to have a higher 759. rate of fracture shortening or other complications compared to traction 2. Pape JM et al. Compartment and delayed casting. Because of the syndrome complicating tibial generally excellent results of spica Tibial tubercle avulsion injuries are tubercle avulsion. Clin Orthop casting in small children, more high energy fractures involving the Relat Res. 1993; 295:201-204 invasive procedures, such as flexible proximal tibial growth center in intramedullary rods, submuscular adolescents. The injuries represent an Question 9 plates, and external fixation, are avulsion type fracture as the proximal reserved for an older age group. tibia growth plate closes from A 2-year-old boy sustained the References: posterior to anterior and from medial isolated injury shown in Figure to lateral. Variations of the fracture 1 after falling from playground 1. Infante AF, et al. Immediate hip pattern can extend through the equipment. The injury was witnessed spica casting for femur fractures in epiphysis into the joint as is clearly and there were no concerns for pediatric patients. A review of 175 shown on the MRI image. This can nonaccidental trauma. The most patients. Clin Orthop & Related sometimes be difficult to detect on appropriate recommendation for Research. 2000;376:106-112. plain radiographs and recent authors treatment should consist of: 2. Mansour AA, et al. Immediate have recommended obtaining A. reduction and internal fixation Spica Casting of Pediatric Femoral advanced imaging such as MRI or using flexible intramedullary Fractures in the Operating CT scan to delineate intra-articular rods. Room Versus the Emergency involvement. Intra-articular fractures Department: Comparison of B. reduction and internal fixation with displacement such as shown Reduction, Complications, using a submuscular locking require open reduction and internal and Hospital Charges.J Pediatr plate. fixation. A known complication from Orthop. 2010;30(8):813-817. this type of injury with significant C. reduction and fixation using an 3. Epps HR, et al. Immediate Single- displacement is the development external fixator. of a compartment syndrome in Leg Spica Cast for Pediatric D. immediate spica casting under the anterior compartment due to Femoral Diaphysis Fractures. J sedation. damage to the recurrent anterior Pediatr Orthop. 2006;26(4):491-496. tibial artery. Premature physeal E. skeletal traction for 1-2 weeks closure is not an issue in a 15 year followed by delayed spica old because this is a transitional casting. fracture which occurs as the growth Correct Answer: D plate is closing. If the patient was

continued on page 14

13 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 13)

Question 10 Department: Comparison of Fig. 1 Fig. 2 Reduction, Complications, When treating a young child with and Hospital Charges.J Pediatr a femoral shaft fracture, which Orthop. 2010;30(8):813-817. statement below regarding proper 2. Epps HR, et al. Immediate Single- technique for placement of a hip spica Leg Spica Cast for Pediatric cast is correct? Femoral Diaphysis Fractures. J A. A short leg cast should be placed Pediatr Orthop. 2006;26(4):491-496. first, traction should be applied, 3. Mubarak SJ, et al. Volkmann Multiple studies have shown a fairly and then the body and upper leg Contracture and Compartment high rate of physeal arrest following portions of the cast should be Syndromes after Femur Fractures physeal injuries to the distal femur. applied and molded. in Children Treated with 90/90 Although individual studies list B. The cast should be applied with Spica Casts. J Pediatr Orthop. varying rates for physeal arrest, the the hip and knee at 90 degrees 2006;26(5):567-572. overall rate is about 60%. The rate (sitting spica cast) has been shown to be higher in cases C. Traction should be applied Question 11 where the initial fracture is displaced. first, followed by applying and Therefore, close follow-up to evaluate molding the body and upper leg A 13-year-old boy sustained an injury for this complication is mandatory. portion of the cast, followed by to his right knee while playing tackle Hardware removal following fracture completing the short leg portion football. He had immediate pain, healing is an option, but remains of the cast, with the hip and knee and the inability bear weight. He controversial. Because of the high flexed less than 90 degrees was evaluated in a local emergency rate of physeal arrest, a contralateral department, and his initial procedure to prevent deformity could D. The cast should be applied in an radiographs are shown in Figures 2a be considered, but most would not operating room under a general and 2b. In addition to open treatment advocate a procedure on the normal anesthetic. of the injury with internal fixation, leg when the incidence of arrest for E. A double-leg spica cast should be management should include: each individual patient cannot be predicted. Because of the fracture applied. A. removal of hardware 6 months instability, and relatively small Correct Answer: C following the injury. amount of internal fixation used, Spica casting has been show to be B. contralateral distal femoral most would advocate a period of effective when the cast is placed physeal arrest to keep his limb immobilization and limited weight by experienced personnel while lengths equal. bearing until some healing is seen the patient is relaxed, whether in C. acute complete arrest of the radiographically. a setting using sedation or general right distal femoral physis and anesthesia. Single-leg spica casts have complete arrest of the left distal References: been shown to be as effective for femoral physis to prevent leg 1. Basener CJ, et al. Growth diaphyseal femur fractures as double- length discrepancy. leg spica casts. To avoid the potential disturbance after distal femoral for compartment syndrome in the leg, D. immediate weight bearing and growth plate fractures in children: the technique of placing of a short knee range of motion exercises. a meta-analysis. J Orthop Trauma. 2009;23(9):663-667. leg/ below knee cast first, applying E. close follow-up for one to two traction and then casting to the trunk years to evaluate for physeal 2. Price CT, Flynn JM. Management and opposite thigh with the hip and arrest, limb length discrepancy, or of Fractures. In: Morrissy RT, knee at 90 degrees flexion should angular deformity. Weinstein ST, eds. Lovell and NOT be used. Winter’s Pediatric Orthopedics. Correct Answer: E 6th ed. Philadelphia, PA: References: Lippincott Williams and Wilkins; 2006:1495-1496. 1. Mansour AA, et al. Immediate Spica Casting of Pediatric Femoral Fractures in the Operating Room Versus the Emergency

14 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 14)

Question 12 spontaneously correct, the patient A. 10% for the lifetime of the child. and family should be counseled about B. 5% for the subsequent 18 months. An 8 year old girl presents to your the risks, benefits, and alternatives clinic with a splint on her right arm of both surgical and non-surgical C. 5% for the subsequent 9 months. and a reported history of fall from management. The callus on this set of D. 1% for the subsequent 18 months. radiographs is mature and would be monkey bars 4 weeks ago. X-rays E. 1% for the subsequent 9 months. are as shown (figure). The injury unlikely to yield with closed means is closed and she is neurologically alone, and attempting a forceful Correct answer: C intact. Her pain is minimal. What closed reduction may injure the Fig. 1 Fig. 2 will you advise as treatment? distal radial physis. Physical therapy generally is not needed in pediatric A. Four more weeks of long arm fracture care. The most likely means casting. of restoring normal anatomy would B. Protective splint for one month, be an open reduction, with osteotomy observation. through the callus/fracture, and C. Physical therapy. fixation with pins. The option of observing the deformity for one year D. Open reduction and fixation. for remodeling, with osteotomy at There are several retrospective series E. Closed reduction and casting. one year from fracture if satisfactory which report on the rate of re-fracture Preferred response: B or D remodeling is not seen, should also after diaphyseal forearm fractures be offered. in children. Most of these cite a 5% Fig. 1 Fig. 2 References: rate. Bould and Bannister stated that the majority of re-fractures occurred 1. Gandhi RK, Wilson P, Mason within 9 months from the original Brown JI, Macleod W. injury, with a median of 8 weeks after Spontaneous correction of cast removal. The rate of re-fracture deformity following fractures of slows down after the first 14-16 the forearm in children. Br J Surg weeks. 1962 (50); 5-10. References: Fig. 3 2. Noonan KJ and Price CT. Forearm and distal radius fractures in 1. Bould M and Bannister GC. children. JAAOS 1998; Refractures of the radius and ulna in children. Injury Int J. Care 3. Perona PG and Light TR. Injured 30 (1999); 583-586. Remodeling of the skeletally immature distal radius. J Orthop 2. Price CT, Scott DS, Kurzner ME, Trauma 1990; 356-361. Flynn JC. Malunited forearm fractures in children. J Pediatr Orthopaed 1990;10:705-12. TThe open physes on the radiographs Question 13 ae consistent with the reported 3. Schwarz N, Pienaar S, Schwarz history of an 8-year old girl, with A 4 year old male had a both bone AF, Jelen M, Styhler W, Mayr hypothetically greater than 2 years forearm fracture 2 months ago J. Refracture of the forearm in of expected growth and remodeling which was well aligned and treated children. J Bone Joint Surg Br. potential. However, the angulation by 6 weeks of casting. Within days 1996 Sep;78(5):740-4. measures at least 40 degrees in the after the last cast was removed, he apex volar direction. Most authors fell again and had immediate pain Question 14 have suggested that the outer limit in the same forearm. X-rays are as for reliable remodeling in children shown (figure). The parents are A 9 year old right hand dominant under 10 years of age is 20-25 angry because you had told them his female sustains the proximal degrees. This is a controversial area. forearm was healed. What percentage humerus fracture shown in Figures risk of re-fracture exists after well- 1A and 1B. While counseling the In cases where the deformity is healed diaphyseal forearm fractures? family on treatment options, you greater than would be expected to

continued on page 16

15 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 15) inform them that: the patient’s non-operatively treated Fig. 1 A. Although there are various fracture at 6 months after injury. In surgical options, open reduction adolescents, this fracture has less with locking plate internal time to remodel, so reduction with fixation is the preferred “standard flexible nails or pin fixation is often of care” treatment. recommended. Threaded Steinman pins offer better fixation than smooth B. Without surgery, she will likely pins; however, they usually require a have a permanent loss of internal return to the OR for removal. rotation. References: C. Because the majority of upper extremity growth comes from the 1. Hutchinson PH, Bae DS, Waters Fig. 2 physes around the elbow, injury PM. Intramedullary nailing to the proximal humeral physis versus percutaneous pin will be well compensated for by fixation of pediatric proximal distal growth. humerus fractures: a comparison of complications and early D. Non-operative treatment such radiographic results. J Pediatr as a sling or hanging arm cast Orthop. 2011 Sep;31(6):617-22. should result in normal range of motion and shoulder function 2. Pahlavan S, Baldwin KD, Pandya within the year. NK, Namdari S, Hosalkar H. Proximal humerus fractures in the E. Threaded pins should be avoided pediatric population: a systematic This patient has sustained an when fixing this fracture due review. J Child Orthop. 2011 avulsion fracture of the anterior to the increased risk of growth June;5(3):187-94. superior iliac spine (ASIS). Because arrest. this is the attachment site of the Answer: D Question 15 sartorius muscle, physical exam of this patient would likely reveal point Fig. 1 Fig. 2 A 15 year old male reports sudden tenderness over the ASIS, pain with pain in his right hip while attempting passive hip extension, and pain/ the long jump at track and field weakness with active hip flexion. practice. After obtaining the Xray Forceful concentric or eccentric in Figure 2A, you recommend the contraction of a muscle attached following: to a specific apophysis (Figure 2B) can result in an avulsion fracture A. Immediate in situ screw fixation at various sites around the pelvis, of his non-displaced slipped Fig. 3 Fig. 4 usually in patients in their mid teens capital femoral epiphysis (pre- to early 20’s. These fractures typically slip). heal nonsurgically with abundant B. Open reduction internal fixation callus. Treatment recommendations of the indirect head of his rectus include initial rest, ice, and analgesics femoris. for the first week, followed by gentle range of motion. Once motion is C. Open reduction internal fixation regained, gentle resistance exercises of the direct head of his rectus are typically started 2-3 weeks after The proximal humeral physis femoris. injury, and more aggressive stretching accounts for approximately 80% D. Protected weight bearing and strengthening are increased of this bone’s longitudinal growth. with crutch use and activity 1-2 months after injury. Surgery is Due to this growth and remodeling restrictions. usually reserved for symptomatic potential, non-operative treatment is nonunions, painful exostoses, and usually recommended for proximal E. MRI to assess for labral injury. fractures displaced greater than 2-3 humeral fractures in young children Preferred Response: D cm or if causing skin tenting or nerve prior to adolescence. Figures 1C & impingement. 1D demonstrate the natural history of Sites of possible apophyseal avulsion

16 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 16) fractures with corresponding Answer: B be used to distinguish injury from muscle attachment: A) iliac crest/ The Delbert Type II fracture pseudosubluxation? abdominal muscles; B) anterior passes through the femoral neck. A. Absence of soft tissue swelling on superior iliac spine(ASIS)/sartorius; Osteonecrosis is reported in as x ray. C) anterior inferior iliac spine (AIIS)/ much as 61% of these fractures. rectus femoris (direct head); D) B. More than 2 mm displacement of Closed reduction alone in the child C2 from Swischuck’s line. ischial tuberosity/hamstrings; E) greater than 4 years of age often symphysis pubis/adductors; F) lesser results in late displacement and C. Smooth contour of the trochanter/iliopsoas; G) greater can contribute to osteonecrosis. If spinolaminar line. trochanter/gluteal muscles. reduction is possible with less than D. All of the above. References: 2 mm displacement and less than 5° Answer: D 1. Holden CP, Holman J, Herman of angulation percutaneous screw Pseudosubluxation, which is an MJ: Pediatric pelvic fractures. fixation insures maintenance of the abnormal alignment of C2 on C3 J Am Acad Orthop Surg. fractures alignment. The 5-year-old seen on the lateral x-ray in children 2007;15(3): 172-7. child will usually not comply with limitation of activities and weight younger than 8, may be difficult 2. McKinney BI, Nelson C, Carrion bearing. External mobilization is to distinguish from injury in the W: Apophyseal avulsion therefore needed. A single sliding setting of neck trauma. Injury to the fractures of the hip and pelvis. screw used to stabilize this fracture cervical spine is more common in Orthopedics. 2009;32(1):42. will not control rotation and would the proximal segments in children 3. Metzmaker JN, Pappas AM: require a small size implant that younger than 8. It is attributed to the Avulsion fractures of the pelvis. may not be available. Traction or fulcrum of motion being greatest at Am J Sports Med. 1985;13(5):349-58. casting alone often results in the the C2-C3 level in the young child development of varus deformity. with a proportionately larger head, 4. Rossi F, Dragoni S: Acute Open reduction is necessary if the compared to the fulcrum at C5-6 level avulsion fractures of the pelvis in fracture is not reducible and is in the adult. Horizontal orientation adolescent competitive athletes: favored by some to decompress of the facet joints and generalized prevalence, location and sports the intra-articular hematoma. ligamentous laxity also contribute to distribution of 203 cases collected. Decompression of the hematoma may this predisposition. Skeletal Radiol. 2001;30(3):127-31. also be accomplished by aspiration A young child’s head is after percutaneous screw fixation. Question 16 disproportionately larger than References: an adult’s. A cross table lateral x-ray may produce flexion of the A 5-year-old child presents to the 1. Rockwood and Wilkins, Fractures cervical spine. The appearance of emergency room after being struck in Children, 2005. pseudosubluxation can be produced by a motor vehicle. The child is found 2. Cheng J,Tang N: Decompression by this flexion. Performing an to have a Delbert Type II hip fracture and stable internal fixation x-ray with a towel roll beneath the and no other injury. X-rays AP and of femoral neck fractures in child’s shoulders may produce a lateral views reveal angulation of children can affect outcome. JPO more natural lateral x-ray and the 10° with 2 mm of displacement of 1999;19:338-343. appearance of pseudosubluxation the femoral neck. The best treatment may be eliminated. option is: Question 17 Two lines may be used to distinguish A. Closed reduction, spica cast pseudosubluxation from injury application. A 6-year-old boy was involved in a -these are Swischuck’s line and the B. Closed reduction, multiple motor vehicle accident. He was not Spinolaminar line. cannulated screw fixation, open restrained and was sitting in the rear Swischuck’s line is drawn along the reduction if needed, spica cast seat of a vehicle. He has stable vital base of the spinous processes from application. signs, is alert, and complains of head pain. He has signs of ecchymosis of C1-C3 on the lateral x-ray. The base of C. Open reduction, single sliding the forehead. Cervical spine films C2 spinous process should be within hip screw fixation. with cross table lateral views are 2 mm of this line. The spinolaminar D. Skeletal traction, delayed spica performed. Subluxation of C2 on C3 line is a curved line drawn along the cast application. is noted. Which of the following may bases of the spinous processes. This continued on page 18

17 Pediatric Sports Medicine: Challenging Cases- what would you do? (from page 17)

should define a smooth arc. Fig. 1 In a study in the Journal of Pediatric Soft tissue swelling of more than one Orthopedics, 15 patients with third of the width of the vertebral Jones fractures were treated with body is abnormal in the anterior an average age of 14. In this study, cervical spine above C4. delayed healing and non-union was noted almost exclusively in patients Despite the use of the above- older than 13. They concluded that mentioned criteria additional younger patients can be treated to diagnostic studies such as flexion union with non-weight bearing short extension radiographs, CTscans and leg casts while older adolescents MRI may be needed to distinguish may benefit from closed reduction and define an injury to the pediatric Fig. 2 intramedullary screw fixation with or cervical spine. without bone grafting to prevent non- References: union or refracture. 1. Shaw M, Burnett H, Wilson References: A, Chan O. Clin Radiology 1. Herrera-Soto JA, Scherb M, Duffy 1999;54:377-380 MF, Albright JC. Fracture of the 2. Cattell HS, Filtzer DL. JBJS Am Fifth Metatarsal in Children and 1965;47(7):1295-1309. Adolescents. J Pediatr Orthop. 2007;27:427-431. Question 18

12 year old female patient presents Fig. 3 with foot pain after a twisting injury one week ago. She presents with the Fractures of the fifth metatarsal following xrays: are very common in children with In regards to this injury: the fifth metatarsal being the most A. The patient should be treated in a commonly injured after age 5. The hard sole shoe, weight bearing as above injury represents a “Jones” tolerated. fracture, which is a fracture just distal to the proximal metadiaphyseal B. The fracture will heal without junction. The healing of these treatment due to the excellent fractures can be delayed due to blood supply at this location. the vascularity in this area. It C. The patient should be treated in is considered a watershed area a short leg cast weight bearing as between the nutrient artery and the tolerated until symptom free. metaphyseal vessels. D. The patient should undergo open These fractures are usually caused reduction internal fixation with by either a direct hit to the foot or a bone grafting. twisting mechanism and are usually seen in athletes in the adolescent E. The patient should be treated in a population. These injuries can be short leg cast, non-weight bearing the result of repetitive stress or a for a minimum of six weeks. traumatic event. Stress reaction at the Answer: E site of the fracture can be indicative of stress prior to fracture.

18 Interview With David Podeszwa, MD (from page 8)

4. Can you give us any early discussion whether this should I think that’s an excellent information as far as your results? be a procedure performed question. One of the things this We are about 20 patients into this throughout the pediatric study may help us with is the and we have not seen a difference orthopaedic community. Dr. timing of this procedure. There in the AVN rate between in-situ Sucato and I have completed will certainly be a wide variety of pinning and hips treated via additional training in this patients who present within an surgical dislocation. procedure, spent hours in the hour of this becoming unstable cadaver lab and performed or some will present days after it 5. You and Dan Sucato are the two numerous dislocations for other becomes unstable. If we can help surgeons that run this trial and diagnoses prior to attempting answer that question “does time are called whenever an unstable an open reduction. We are matter?” I think that will help SCFE comes in. In effect, this developing an expertise in this answer this question. Currently, is a separate call for unstable procedure in order to provide the my belief is that there is a role for slips and TSRH is probably safest care that we can. in-situ pinning and performing one of the few institutions with 6. Going forward, do you think an open reduction in a delayed this type of coverage. What fashion. I think it should be done do you believe are advantages having a separate SCFE call is something that you may consider within six weeks from the time and disadvantages of having an of in-situ pinning. Certainly, if unstable SCFE call roster? maintaining after the study is over in order to give the patients you could offer the patient one The primary utility is for who come in all options? Should surgery versus two surgeries, execution of the randomized we move to another model it would probably be better trial; Dr. Sucato and I are the that has been proposed where for them. That being said, if a only two surgeons performing whoever is on general call pins surgeon does not have experience the open reductions. Clearly, the SCFE in-situ and if the with an open reduction, in-situ pinning is a procedure all deformity is significant enough, performing an in-situ pinning and pediatric orthopaedic surgeons you or Dr. Sucato would perform referring to an institution with can perform, but an open a dislocation at a later date to greater expertise may be in the reduction is a far more complex. improve the deformity? best interest of the child. Recently, there has been a lot of

Mark the date: Monday September 23, 2013 Fellowship Match Webinar

The BOS Match Committee will host a free webinar on September 23rd at 8pm Eastern titled “Tips for the Orthopaedic Fellowship Match. Webinar participants will learn helpful match statistics for each subspecialty match for the past 4 years, tips from program directors’ and information on what to look for in choosing a fellowship.

19 IPOS 2013: Learning at the edge… Annual symposium offers unique, interactive and international learning experience

Now in its 10th year, the surgeon, you should find Call for Resident Participation International Pediatric Orthopaedic programming of interest” says Residents are being strongly Symposium presented by Michael G Vitale, MD MPH, course encouraged to submit a structured AAOS and POSNA is a premier director. “IPOS seeks to speak to the case presentation which will be educational event focused on diverse interests found in our field” graded by the advisory board. The treating orthopaedic conditions This year will include session on top presentations will be selected for in young patients. This year’s Managing Complications, Lower presentation on the new Tuesday eve symposium will be held on Extremity Problems in the Young session. Additionally, residents and December 4-7, 2013 at the Walt Athlete, Innovative Techniques in fellows will be asked to participate Disney World Swan Resort in Lake the Pediatric Hip, Surgical Treatment in the Thursday evening Top Gun Buena Vista (Orlando), Florida of the Neuromuscular Patient, and presentation. The four-day IPOS program, led Kids in the Clinic. Registrants can For more information about IPOS by Course Director Michael G choose from five or six specialty 2013, visit http://www.posna.org/ Vitale, MD MPH, is a unique blend breakout sessions on topics such as ipos/ipos.asp. of lectures, breakout sessions and femoral acetabular impingement, hands-on workshops. Recognizing principles of limb deformity the diversity and subspecialty correction, challenging sports cases, interests within pediatric advanced Ponseti casting, hands-on orthopaedics, participants can pelvic osteotomy workshop, and customize their learning experience selection fusion levels for idiopathic by choosing from a selection scoliosis. The course covers all areas of over 45 breakout sessions, of pediatric orthopaedics—including demonstrations, high-level hands-on sports medicine, trauma, spine, hip, technical workshops, and industry- upper extremity, and more, from sponsored sessions. frequently-seen problems to rare This year IPOS will further its conditions that demand specialized innovative approach in a number of care. ways. Tuesday evening, for example, International influence will provide an opportunity for early arrivals to come to a “Cases and The unique perspectives that Cocktail” session with residents who international faculty bring to the were awarded grants competing program is one of the attractions for “Best Case Presentation”. The of IPOS. “They often bring cutting- Masters Technique session will edge ideas not yet popular in the again be recorded so that IPOS U.S and actively debate with the attendees can access these technical U.S. faculty on the optimal care for tips year round. On Friday, IPOS different conditions,” notesDr. Jack will broadcast the Pediatric Trauma Flynn, Co Chair of IPOS 2013. Breakout internationally in the first Whether you are an experienced Webinar in IPOS history. And again, orthopaedic surgeon, resident, residents will compete during the fellow, or allied health provider, if surgical simulation program (Top your practice includes children or Gun), again led by Don Bae this young athletes, this symposium year. updates you on today’s cutting- “In organizing IPOS, we seek to edge issues in pediatric orthopaedic have every square filled. Whether surgery and prepares you to meet you are a PA, resident, Fellow or the diagnostic, procedural, and super-specialized experienced management challenges of their care needs.